Level: Foundational
Difficulty: Easy
Subtopic: Shock states
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to shock states. Ass…
Pathophysiology Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to shock states. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. 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.