Level: Clinical
Difficulty: Medium
Subtopic: Hematologic disorders
NCLEX: A 45-year-old client in the emergency department is being evaluated for pancytopenia after chemotherapy. Assessme…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for pancytopenia after chemotherapy. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. "The client is doing fine; no issues to report."
B. SBAR format with specific objective findings, current status, and a clear recommendation.
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
B. SBAR format with specific objective findings, current status, and a clear recommendation.
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: B. SBAR format with specific objective findings, current status, and a clear recommendation.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Handoff and escalation require concise, objective communication such as SBAR with current assessment data.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.