Level: Foundational
Difficulty: Easy
Subtopic: Hydration and fluid balance
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to hydration and flui…
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to hydration and fluid balance. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. "The client is doing fine; no issues to report."
B. Vague statements without measurable assessment data.
C. Blaming the client for nonadherence instead of stating facts.
D. SBAR format with specific objective findings, current status, and a clear recommendation.
B. Vague statements without measurable assessment data.
C. Blaming the client for nonadherence instead of stating facts.
D. SBAR format with specific objective findings, current status, and a clear recommendation.
Rationale
Correct answer: D. 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.