Level: Clinical
Difficulty: Medium
Subtopic: Anticoagulants
NCLEX: A 45-year-old client in the emergency department is being evaluated for warfarin anticoagulation. Assessment data…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 45-year-old client in the emergency department is being evaluated for warfarin anticoagulation. Assessment data include the client has respiratory rate 10/min and is difficult to arouse after opioid administration. 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.