Level: Clinical
Difficulty: Medium
Subtopic: Clotting and bleeding disorders
NCLEX: A 45-year-old client in the emergency department is being evaluated for clotting and bleeding disorder. Assessmen…
Pathophysiology Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for clotting and bleeding disorder. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. 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. SBAR format with specific objective findings, current status, and a clear recommendation.
D. Blaming the client for nonadherence instead of stating facts.
B. Vague statements without measurable assessment data.
C. SBAR format with specific objective findings, current status, and a clear recommendation.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: C. 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.