Level: Foundational
Difficulty: Easy
Subtopic: Pre-clinical preparation
NCLEX: A senior nursing student during a supervised medication pass is being evaluated for transition-to-practice skills…
Professional nursing practice (clinical transition) Management of Care
Case Study
A senior nursing student during a supervised medication pass is being evaluated for transition-to-practice skills and pre-clinical preparation. Assessment data include the student receives feedback about incomplete SBAR during handoff. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that the student receives feedback about incomplete SBAR during handoff.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that the student receives feedback about incomplete SBAR during handoff.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that the student receives feedback about incomplete SBAR during handoff.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.