Level: Clinical
Difficulty: Medium
Subtopic: Enzymes and metabolic pathways
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to enzymes and metab…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to enzymes and metabolic pathways. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. SBAR format with specific objective findings, current status, and a clear recommendation.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: A. 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.