A nurse is reviewing the client's medical record and notices a family history of malignant hyperthermia. In which of the following sections of the SBAR communication tool should the nurse include this information when completing handoff to the surgical team?

Background

Recommendation

Situation

Assessment

Answer and Explanation

The Correct Answer is A

A. The Background section of the SBAR communication tool is where relevant medical history, including a family history of malignant hyperthermia, should be included. This information is critical for the surgical team to be aware of before administering anesthesia.

B. The Recommendation section is for suggesting specific actions or interventions based on the current situation and background.

C. The Situation section describes the immediate issue or reason for the handoff, not past medical history.

D. The Assessment section includes the nurse's evaluation of the client’s current condition, not family history.

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Correct Answer is D

Explanation

A. Increased systemic vascular resistance is more characteristic of obstructive or cardiogenic shock rather than distributive shock.

B. Loss of blood volume describes hypovolemic shock, not distributive shock.

C. Loss of myocardial contractility pertains to cardiogenic shock, not distributive shock.

D. Distributive shock is characterized by systemic vasodilation leading to a decrease in systemic vascular resistance and inadequate tissue perfusion.

A. "Use the incentive spirometer once every 4 hours." B. "Inhale through the incentive spirometer 10 times with each use." C. "Sit up at a 30-degree angle when using the incentive spirometer." D. "Hold your breath for 7 seconds when using the incentive spirometer."

Correct Answer is B

Explanation

A. The incentive spirometer should typically be used more frequently, often every 1-2 hours while awake, rather than every 4 hours.

B. Inhaling deeply and holding the breath for a few seconds (often 5-10) is a common recommendation for effective use of the incentive spirometer to maximize lung expansion.

C. The client should be in a sitting position or at a 45-degree angle for optimal use, not just 30 degrees.

D. The recommended breath hold time is usually around 5-10 seconds, not 7 seconds, depending on the specific guidelines provided by the healthcare team.

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A nurse is reviewing the client's medical record and notices a family history of malignant hyperthermia. In which of the following sections of the SBAR communication tool should the nurse include this information when completing handoff to the surgical team?

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