NursGuru
    Nurs 547 Med Surg Proctored Exam(Examplify)
    The nurse is receiving the SBAR note below. Select to highlight the five findings from the report that are the most concerning and require immediate action by the nurse. SBAR Report: Situation: S.B. is a 54-year-old female patient who had bariatric surgery 2 days ago. Their current weight is 118 kg. The patient is allergic to shellfish. Background: The patient has a medical history of obesity. Assessment. The patients' vital signs are BP 80/48 mmHg, HR 138 beats per minute, RR 32 breaths per minute, Temp. 99.9° F, and a Pulse Oximetry of 91% on room air. The patient is A&0 x2, the lungs are clear bilaterally, heart sounds are S1S2 and bounding. Sinus tachycardia on the monitor. They report 10/10 generalized abdominal pain, and they have voided 300 ml over the past 12-hour shift. WBCs are 13,000/mm3 (reference range 4,500-11,000/mm3), Potassium 3.4 mEq/L (reference range 3.5-5 mEq/L) BUN 28 mg/dL (reference range 10-20 mg/dL), Glucose 128 mg/dL (reference range 70-110 mg/dL) and the Lactate is 6 mmol/L (reference range <1.25 mmol/L). Response/Recommendation: The patient has orders for Acetaminophen 1 gm PO every 4 hours PRN for temperature >100.8°F, Ceftriaxone 2 gm IV every 8 hours, Pantoprazole 40 mg IV twice daily, Potassium Chloride 40 mEq PO x once, and 0.9% Sodium Chloride per sepsis protocol. She needs a nutritional consult.

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