During a preoperative assessment phone call, a client reports taking several “pills” every day. Which response should the office nurse provide?

Choice A reason: Explaining the reason for urgent notification (fever during PRBC transfusion) is critical first in SBAR, as it conveys the situation, identifying a potential transfusion reaction. This prioritizes the provider’s focus on a life-threatening issue, ensuring timely intervention to prevent complications like hemolysis.

Choice B reason: Obtaining a prescription for acetaminophen treats fever but is a recommendation, not the first SBAR step. The situation (fever during transfusion) must be communicated first to alert the provider, making this action secondary to explaining the urgent issue.

Choice C reason: Communicating pretransfusion temperatures is background data, not the first SBAR step. The situation (fever during transfusion) takes precedence, as it signals a potential reaction, and temperature context follows, making this information less immediate than the reason for notification.

Choice D reason: Starting with the client’s name and diagnosis is part of background, not the first SBAR step. The situation (fever during transfusion) must be stated first to highlight urgency, ensuring the provider addresses the potential reaction promptly, making this less critical initially.

Choice A reason: Elevating extremities reduces edema but does not address absent pulses, indicating possible arterial occlusion post-AAA repair. Doppler assessment confirms pulse status, identifying critical ischemia, and elevation is secondary, as it does not diagnose the underlying vascular compromise requiring urgent intervention.

Choice B reason: Administering a diuretic treats edema but ignores absent pulses, a sign of arterial compromise post-AAA repair. Doppler assessment identifies ischemia, and diuretics may worsen hypovolemia, risking graft failure, making this action less urgent than confirming vascular patency.

Choice C reason: Evaluating edema provides data but does not prioritize absent pulses, suggesting arterial occlusion post-AAA repair. Doppler assessment directly confirms pulse status, guiding urgent vascular intervention, and edema evaluation is secondary, as pulses indicate a more immediate threat to limb viability.

Choice D reason: Assessing distal pulses with Doppler is critical first, as absent pulses post-AAA repair suggest graft thrombosis or arterial occlusion, risking limb ischemia. Doppler confirms pulse presence, guiding urgent surgical consultation, making it the priority to prevent irreversible tissue damage or amputation.