What is the correct SBAR sequence?
Items to be Ordered
I fear it might be peritonitis or bleed. Suggest immediate evaluation, abdominal CT, increased IV fluids, and broader antibiotic coverage.
This is nurse Johnson on the surgical unit. Calling about Mr. Davis, 6 hours post-appendectomy, with severe pain and worsening vitals.
Post-op Day 0 from appendectomy 6 hrs ago. History of HTN, takes lisinopril. Received morphine 4mg IV 2 hours ago with minimal relief.
Pain is 9/10, abdomen rigid/distended, restless. Vitals: HR 115, BP 90/58, RR 24, Temp 101.2 F Bowel sounds absent.
The Correct Answer is B,C,D,A
SBAR is a standardized communication framework used in clinical handover to ensure patient safety, reduce errors, and improve escalation of care by structuring information into Situation, Background, Assessment, and Recommendation to support rapid clinical decision-making in deteriorating patients.
Rationale:
B. Situation is the first SBAR component and identifies the caller, location, patient, and immediate problem. This establishes context for communication. The nurse introduces self, unit, patient identity, postoperative status, and reason for call, which defines the urgent clinical situation requiring escalation.
C. Background provides relevant clinical history and predisposing factors contributing to current condition. This includes post-operative status, comorbid hypertension, medication use, and prior analgesia response. It supplies essential contextual data without interpretation of current deterioration, forming baseline clinical information.
D. Assessment describes current clinical findings including vital signs, abdominal rigidity, severe pain, and signs of shock or sepsis. These objective and subjective findings indicate acute deterioration and possible intra-abdominal complication, forming the nurse’s clinical evaluation of patient status.
A. Recommendation states the suggested clinical actions such as urgent evaluation, imaging, fluid resuscitation, and antibiotic escalation. This final step communicates expected interventions based on suspected peritonitis or hemorrhage, completing SBAR with actionable clinical direction for provider response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Tongue movement is primarily controlled by cranial nerve XII (hypoglossal nerve), which innervates intrinsic and extrinsic tongue muscles responsible for articulation, swallowing, and midline protrusion. Proper function reflects intact motor innervation without unilateral weakness or deviation.
Rationale:
A. Loss of CN XII function results in tongue deviation toward the affected side due to unopposed action of the contralateral genioglossus muscle. Atrophy, fasciculations, and impaired articulation may also be present. A midline protrusion would not be expected in dysfunction.
B. Intact CN XII is indicated by a tongue that protrudes straight midline without deviation. This reflects normal hypoglossal nerve motor function and balanced muscular activity of both sides of the tongue during voluntary movement.
C. CN IX (glossopharyngeal nerve) is primarily responsible for taste sensation in the posterior one-third of the tongue and swallowing reflexes. It does not control tongue protrusion, so its dysfunction would not affect midline movement.
D. Intact CN IX relates to normal gag reflex and posterior tongue sensation but does not influence tongue motor control. Midline protrusion is not dependent on glossopharyngeal nerve integrity, making this option incorrect.
Correct Answer is D
Explanation
Priority-setting in acute care follows the ABCs framework (airway, breathing, circulation) and focuses on immediate threats to oxygenation and ventilation. Patients with respiratory compromise, especially those with COPD and artificial airways, are at high risk for rapid deterioration due to airway obstruction, secretion retention, and impaired gas exchange.
Rationale:
A. 5.1 mmol/L is only mildly elevated and does not indicate immediate life-threatening hyperkalemia. The patient is stable while awaiting sodium polystyrene sulfonate. No ECG changes or severe electrolyte imbalance are described, so this is not the first priority.
B. Post-PCI patients require monitoring for complications such as bleeding or retroperitoneal hemorrhage. However, a stable groin site and mild backache rated 4/10 suggest no immediate hemodynamic instability. This finding warrants assessment but is not the highest priority.
C. Missed phenytoin dose due to low albumin is important but not immediately life-threatening. While seizure risk may increase, there is no active seizure or neurologic deterioration described. This represents a medication management issue rather than an acute emergency.
D. A COPD patient with a tracheostomy and sudden increase in noisy respirations indicates possible airway obstruction from mucus plugging or secretion buildup. The elevated heart rate suggests early respiratory distress and hypoxemia. This is an immediate airway emergency requiring urgent assessment.
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