Level: Clinical
Difficulty: Medium
Subtopic: Congenital disorders
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for newly diagnosed congenital heart disease. Ass…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for newly diagnosed congenital heart disease. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which communication to the oncoming nurse or provider is most appropriate?
Question
A. SBAR format with specific objective findings, current status, and a clear recommendation.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
B. "The client is doing fine; no issues to report."
C. Vague statements without measurable assessment data.
D. Blaming the client for nonadherence instead of stating facts.
Rationale
Correct answer: A. 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.