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 C

Explanation

A. Distended neck veins are typically associated with fluid overload, not dehydration.

B. An elevated blood pressure is not a common indicator of dehydration; dehydration often leads to hypotension.

C. An elevated urine specific gravity (greater than 1.030) indicates concentrated urine, which is a sign of dehydration as the body conserves water.

D. A bounding pulse is more indicative of fluid overload rather than dehydration, which often causes a weak, thready pulse.

A. Immobility B. Fracture C. Atrial fibrillation D. Anticoagulant therapy

Correct Answer is ["A","B","E"]

Explanation

A. Immobility is a significant risk factor for DVT because it can lead to blood stasis in the veins, increasing the risk of clot formation.

B. Fractures, particularly of the lower limbs, can lead to immobilization and contribute to the development of DVT.

C. Atrial fibrillation is associated with an increased risk of clot formation, but these clots typically form in the atria of the heart, not the deep veins. While these clots can embolize to other parts of the body, atrial fibrillation itself is not a direct cause of DVT.

D. Anticoagulant therapy is typically used to prevent DVT, not as a risk factor.

E. Estrogen therapy is associated with an increased risk of clot formation, making it a risk factor for DVT.

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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?

Nursing Test Bank

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