Level: Clinical
Difficulty: Medium
Subtopic: Mandatory reporting
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to mandatory reportin…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to mandatory reporting. Assessment data include new chest pain rated 8/10 with diaphoresis. 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.