Level: Clinical
Difficulty: Medium
Subtopic: SBAR handoff
NCLEX: A new graduate nurse working with a preceptor is being evaluated for transition-to-practice skills and sbar hando…
Professional nursing practice (clinical transition) Management of Care
Case Study
A new graduate nurse working with a preceptor is being evaluated for transition-to-practice skills and sbar handoff. Assessment data include the student receives feedback about incomplete SBAR during handoff. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
Rationale
Correct answer: A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.