A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells (PRBCs). When notifying the healthcare provider (HCP), which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process? 

Choice A reason: Contact precautions prevent MRSA spread, as it transmits via direct contact or contaminated surfaces. Isolation with gowns and gloves reduces nosocomial infection risk, critical for protecting staff and patients, making this a key intervention in the plan of care for suspected MRSA.

Choice B reason: Administering vancomycin is essential, as it treats MRSA, a resistant bacterium requiring specific antibiotics. Vancomycin targets cell wall synthesis, effective against MRSA, and prompt administration prevents systemic spread, making it a critical intervention for confirmed or suspected infections.

Choice C reason: Obtaining a wound culture confirms MRSA diagnosis by identifying the pathogen and its antibiotic sensitivity. This guides targeted therapy, ensuring effective treatment and preventing resistance, making it a vital step in managing suspected MRSA infections in the care plan.

Choice D reason: Monitoring white blood cell count tracks infection severity, as leukocytosis indicates MRSA’s systemic inflammatory response. This helps assess treatment response and complications, making it an important intervention to evaluate the client’s condition and guide ongoing management of the infection.

Choice E reason: Ensuring hand hygiene compliance prevents MRSA transmission, a highly contagious pathogen spread via contact. Rigorous handwashing reduces cross-contamination, protecting the client, staff, and others, making it an essential intervention in the care plan for infection control.

Choice A reason: Palpable cervical lymph nodes suggest infection or malignancy, not stroke risk. Stroke is linked to vascular issues like carotid stenosis, detected by bruit. Lymph nodes are unrelated to cerebrovascular pathology, making this finding irrelevant for identifying stroke risk in the client.

Choice B reason: Carotid bruit indicates turbulent flow from stenosis, a major stroke risk due to potential embolism or reduced cerebral perfusion. This vascular finding directly correlates with ischemic stroke, making it the most critical assessment to report for stroke prevention and evaluation.

Choice C reason: Nuchal rigidity suggests meningitis or subarachnoid hemorrhage, not ischemic stroke risk. Carotid bruit is a specific precursor to embolic stroke, and nuchal rigidity addresses different neurological conditions, making this finding less relevant for stroke risk assessment.

Choice D reason: Jugular vein distention indicates heart failure or venous pressure, not arterial stroke risk. Carotid bruit directly relates to cerebrovascular disease, a stroke precursor, making jugular distention irrelevant, as it reflects cardiovascular, not cerebrovascular, pathology in stroke risk evaluation.