Level: Foundational
Difficulty: Easy
Subtopic: Vital signs
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for postoperative monitoring. Assessment dat…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for postoperative monitoring. Assessment data include pain 9/10 and guards the abdomen after surgery. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. "The client is doing fine; no issues to report."
B. SBAR format with specific objective findings, current status, and a clear recommendation.
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
B. SBAR format with specific objective findings, current status, and a clear recommendation.
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: B. 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.