Level: Foundational
Difficulty: Easy
Subtopic: Recognize cues
NCLEX: An RN prioritizing care after a change in status is being evaluated for unfolding changes in a case study. Assess…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for unfolding changes in a case study. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. 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.