Level: Clinical
Difficulty: Medium
Subtopic: Skin integrity
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to skin integrity….
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 nursing care related to skin integrity. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. 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.