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.

Rationale for correct choices &bull; Blood pressure 80/48 mmHg: Severely low blood pressure indicates hypotensive shock, which can compromise perfusion to vital organs. Immediate intervention is required to prevent organ failure and maintain hemodynamic stability. This finding is especially concerning in recent surgery and potential sepsis. &bull; Heart rate 138 beats/minute (sinus tachycardia): Tachycardia is a compensatory response to hypotension and decreased perfusion. It signals that the cardiovascular system is under stress and the patient may be in early shock, requiring rapid assessment and treatment of underlying causes. &bull; Respiratory rate 32 breaths/minute: Tachypnea may indicate metabolic acidosis, hypoxemia, or early respiratory compromise. Elevated respiratory rate increases oxygen demand and signals the patient is physiologically stressed, warranting urgent monitoring and intervention. &bull; Lactate 6 mmol/L: An elevated lactate indicates tissue hypoperfusion and anaerobic metabolism, a hallmark of sepsis or shock. This level is critically high and requires immediate action to restore perfusion and prevent multi-organ failure. &bull; WBC 13,000/mm&sup3;: Leukocytosis indicates an inflammatory response, likely secondary to infection, and when combined with hypotension, tachycardia, and elevated lactate, strongly suggests sepsis. Prompt recognition and intervention are critical to prevent deterioration. Rationale for incorrect choices &bull; Temperature 99.9&deg;F: While mildly elevated, this temperature does not meet fever criteria (>100.4&deg;F) and is less urgent compared to hypotension, tachycardia, and elevated lactate. &bull; Potassium 3.4 mEq/L: This is a mild hypokalemia that requires monitoring and replacement but does not constitute an immediate life-threatening condition compared to hypotension or elevated lactate. &bull; BUN 28 mg/Dl: Elevated BUN indicates possible dehydration or renal stress but is not immediately life-threatening. It should be addressed after stabilizing hemodynamics.