Level: Foundational
Difficulty: Easy
Subtopic: Skills lab checkoff
NCLEX: The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and skills la…
Professional nursing practice (clinical transition) Management of Care
Case Study
The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and skills lab checkoff. 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. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that the student receives feedback about incomplete SBAR during handoff.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that the student receives feedback about incomplete SBAR during handoff.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. 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.