Level: Foundational
Difficulty: Easy
Subtopic: Beneficence and nonmaleficence
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to beneficence and nonmalefi…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for nursing care related to beneficence and nonmaleficence. Assessment data include telephone order received for a high-risk IV medication. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. "The client is doing fine; no issues to report."
B. Vague statements without measurable assessment data.
C. SBAR format with specific objective findings, current status, and a clear recommendation.
D. Blaming the client for nonadherence instead of stating facts.
B. Vague statements without measurable assessment data.
C. SBAR format with specific objective findings, current status, and a clear recommendation.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: C. 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.