Level: Advanced
Difficulty: Hard
Subtopic: Safety-focused judgment
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to safety-focused ju…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for nursing care related to safety-focused judgment. Assessment data include the medication record, labs, and assessment notes contain conflicting cues. 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.