Communication And Handoff (SBAR)
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NCLEX-RN › Communication And Handoff (SBAR)
A nurse in an acute care setting notes a critical change in condition in a 74-year-old client with chronic obstructive pulmonary disease and heart failure admitted for pneumonia; the client is suddenly more confused with respiratory rate 30/min, oxygen saturation 86% on 4 L nasal cannula, heart rate 124/min, blood pressure 148/84 mm Hg, and audible wheezing. What is the MOST important recommendation for the nurse to communicate using SBAR when calling the healthcare provider?
Ask whether the client can have a regular diet and if physical therapy can start today to prevent deconditioning.
Request an order to increase oxygen delivery and evaluate for respiratory support due to worsening hypoxia and increased work of breathing.
Report that the client has been hospitalized twice this year and prefers to sleep in a recliner at home.
State that the client is wheezing and confused but omit current oxygen flow rate and oxygen saturation to keep the report brief.
Explanation
This question tests SBAR communication and clinical judgment when reporting a critical change to a healthcare provider. SBAR is important for ensuring effective handoffs by organizing information to facilitate quick decision-making and enhance client safety in acute situations. The correct answer, choice A, is the most effective SBAR communication because it provides a clear recommendation to address worsening hypoxia and respiratory distress through increased oxygen and evaluation for support, directly targeting the urgent needs. Choice B suggests non-urgent requests for diet and therapy, choice C includes irrelevant background on hospitalizations and sleep preferences, and choice D omits critical details like oxygen saturation, compromising the report's completeness. The decision-making principle in SBAR communication is to include specific, actionable recommendations based on assessed changes to prompt appropriate provider responses. This approach minimizes errors and supports rapid intervention in deteriorating conditions. A transferable strategy for improving communication skills is to rehearse SBAR calls with peers, focusing on including all vital data to build confidence in high-stakes reporting.
A nurse calls the healthcare provider about a 65-year-old client with Parkinson disease who is hospitalized for dehydration; current assessment shows new coughing during meals, drooling, respiratory rate 22/min, oxygen saturation 92% on room air, and coarse breath sounds after lunch. What is the MOST important recommendation for the nurse to communicate using SBAR?
Request orders to keep the client nothing by mouth until evaluated and to obtain a swallow evaluation due to aspiration risk.
Request a change to the nighttime sleep routine to help the client rest longer.
Ask for a referral to social work to discuss transportation after discharge.
Recommend continuing the current diet because coughing is expected in older adults.
Explanation
This question tests SBAR communication and clinical judgment when calling a provider about swallowing issues. SBAR is important for ensuring effective handoffs by advocating for interventions that prevent aspiration and maintain airway safety. The correct answer, choice A, is the most effective SBAR communication because it recommends NPO status and swallow evaluation for signs like coughing and coarse sounds, addressing aspiration risk. Choice B suggests sleep routine changes, choice C requests social work, and choice D dismisses coughing as normal. The decision-making principle in SBAR communication is to recommend protective measures based on assessment of neurological symptoms. This prevents complications in chronic conditions like Parkinson. A transferable strategy for improving communication skills is to use SBAR to advocate for evaluations in cases of subtle symptom changes.
A nurse is transferring a 56-year-old client with a history of atrial fibrillation on anticoagulation from the medical unit to radiology for a computed tomography scan after a fall; current assessment shows blood pressure 104/66 mm Hg, heart rate 110/min irregular, respiratory rate 18/min, oxygen saturation 95% on room air, headache 7/10, and new right arm weakness. What information should the nurse include in the SBAR report to the receiving department to support safe transfer?
Background: The client enjoys gardening, has two adult children, and prefers not to receive visitors during the day.
Assessment: The client is stable for transport; no need to mention anticoagulant use because it is listed in the chart.
Situation/Assessment: The client fell, is on anticoagulation, and now has a severe headache with new right arm weakness; current vital signs are 104/66, 110 irregular, 18, and 95% on room air.
Recommendation: Plan to discuss long-term fall-prevention strategies and arrange a home safety evaluation after discharge.
Explanation
This question tests SBAR communication and clinical judgment during a client transfer to radiology. SBAR is important for ensuring effective handoffs by standardizing information to prevent oversights and promote safety during transitions of care. The correct answer, choice A, is the most effective SBAR communication because it combines situation and assessment to highlight critical signs like headache, weakness, and vital signs in an anticoagulated client post-fall, alerting to possible bleeding risks. Choice B provides irrelevant background on hobbies and visitors, choice C focuses on long-term recommendations like fall prevention, and choice D minimizes anticoagulant details and assumes chart review, risking incomplete transfer information. The decision-making principle in SBAR communication is to emphasize urgent assessment findings that could impact immediate safety during transfers. This ensures the receiving team is prepared for potential emergencies like intracranial hemorrhage. A transferable strategy for improving communication skills is to use SBAR checklists during transfers to systematically include all essential elements and reduce communication gaps.
A nurse is transferring a 39-year-old client with a history of seizures to the imaging department for magnetic resonance imaging; current assessment shows the client is alert, blood pressure 126/80 mm Hg, heart rate 84/min, and reports having missed the morning seizure medication due to nausea. What information should the nurse include in the SBAR report for a safe and effective transfer?
Situation/Background: The client has a seizure history and missed the morning seizure medication; current vital signs are stable and the client is alert.
Background: The clients favorite music helps with relaxation; request that staff play it during the scan.
Assessment: The client is stable; omit missed medication because it is not relevant to the scan.
Recommendation: Ask imaging staff to provide detailed teaching on seizure management after discharge.
Explanation
This question tests SBAR communication and clinical judgment during a transfer to imaging. SBAR is important for ensuring effective handoffs by including medication and history details to prevent risks during procedures. The correct answer, choice A, is the most effective SBAR communication because it combines situation and background on missed seizure medication with stable assessment, alerting to seizure risk. Choice B requests music, choice C recommends teaching, and choice D omits medication details. The decision-making principle in SBAR communication is to convey relevant history impacting procedure safety like seizure potential. This prepares teams for emergencies. A transferable strategy for improving communication skills is to include risk factors in SBAR transfers, enhancing procedural safety awareness.
A nurse calls the provider about a 63-year-old client with a history of benign prostatic enlargement who has not voided for 10 hours; current assessment shows suprapubic discomfort, bladder scan 850 mL, blood pressure 142/86 mm Hg, heart rate 98/min, and restlessness. What is the MOST important recommendation for the nurse to communicate using SBAR?
Recommend encouraging the client to drink more fluids to stimulate urination without addressing bladder volume.
Recommend waiting until morning rounds because urinary retention often resolves overnight.
Request that the client be scheduled for nutrition counseling to reduce evening fluid intake long term.
Request an order for urinary catheterization or a specific protocol to relieve acute urinary retention.
Explanation
This question tests SBAR communication and clinical judgment when calling a provider about urinary retention. SBAR is important for ensuring effective handoffs by recommending interventions for uncomfortable symptoms to prevent complications and ensure safety. The correct answer, choice A, is the most effective SBAR communication because it requests catheterization or protocol for high bladder volume and discomfort, addressing acute retention. Choice B suggests nutrition counseling, choice C recommends waiting, and choice D encourages more fluids without resolution. The decision-making principle in SBAR communication is to propose direct solutions for assessed issues like retention in prostatic conditions. This alleviates symptoms and avoids infections. A transferable strategy for improving communication skills is to use SBAR for symptom-based calls, clearly stating recommended actions.
During shift change, the nurse gives handoff on a 59-year-old client with coronary artery disease who is 1 day after a cardiac catheterization via the right groin; current assessment shows blood pressure 118/72 mm Hg, heart rate 88/min, and a new firm swelling and bruising at the groin site with pain 8/10 and a decreased right pedal pulse compared with the left. What information should the nurse include in the SBAR report?
Situation: The groin looks different; Background: the client had a catheterization; Assessment: the nurse thinks it is probably normal bruising.
Recommendation: Encourage walking in the hallway every hour to prevent constipation.
Background: The client is worried about returning to work and would like information about cardiac-healthy recipes.
Situation/Assessment: New firm swelling and bruising at the right groin access site with severe pain and decreased right pedal pulse compared with the left; current vital signs are stable.
Explanation
This question tests SBAR communication and clinical judgment during a shift-change handoff for a post-catheterization client. SBAR is important for ensuring effective handoffs by emphasizing changes that could indicate complications, promoting client safety. The correct answer, choice A, is the most effective SBAR communication because it describes the situation and assessment of groin swelling, pain, and decreased pulse suggesting vascular compromise, requiring prompt attention. Choice B focuses on work worries and recipes, choice C recommends ambulation for constipation, and choice D vaguely describes the issue without clear assessment. The decision-making principle in SBAR communication is to provide detailed objective findings of potential complications to enable quick recognition. This prevents delays in addressing issues like hematoma or occlusion. A transferable strategy for improving communication skills is to simulate handoff scenarios, practicing articulation of assessment details for post-procedure clients.
A nurse calls the provider about a 66-year-old client with a history of heart failure who reports sudden shortness of breath; current assessment shows respiratory rate 32/min, oxygen saturation 84% on room air, heart rate 118/min, blood pressure 178/96 mm Hg, and new crackles in both lungs. What is the MOST important recommendation for the nurse to communicate using SBAR?
Recommend waiting to reassess after the client rests because anxiety can cause shortness of breath.
Request an order for a stool softener because the client has not had a bowel movement today.
Request immediate evaluation and orders for oxygen support and treatment for acute breathing difficulty based on severe hypoxia and lung crackles.
Recommend limiting fluids for the next month and scheduling a follow-up appointment after discharge.
Explanation
This question tests SBAR communication and clinical judgment when calling a provider about acute shortness of breath. SBAR is important for ensuring effective handoffs by recommending urgent actions for respiratory distress to safeguard client stability. The correct answer, choice A, is the most effective SBAR communication because it requests evaluation and oxygen for hypoxia and crackles suggesting pulmonary edema. Choice B suggests stool softener, choice C recommends fluid limits long-term, and choice D advises waiting for rest. The decision-making principle in SBAR communication is to link recommendations to acute findings for immediate heart failure management. This prevents respiratory failure progression. A transferable strategy for improving communication skills is to prioritize urgency in SBAR calls, practicing with respiratory emergency scenarios.
During shift-change handoff, the nurse reports on a 58-year-old client with chronic liver disease admitted for abdominal swelling; current assessment shows increasing abdominal girth, shortness of breath when lying flat, blood pressure 106/64 mm Hg, heart rate 104/min, and oxygen saturation 94% on room air. The nurse should focus on which aspect of SBAR to ensure effective communication?
Focus only on background liver history and omit current symptoms because they may fluctuate.
Provide a concise assessment of breathing status and abdominal changes and include what monitoring or provider notification is needed if symptoms worsen.
Mix situation and recommendation by stating, He needs a procedure today, without providing current assessment findings.
Include a detailed description of the clients family dynamics and coping style as the main focus.
Explanation
This question tests SBAR communication and clinical judgment in a shift-change handoff for liver disease. SBAR is important for ensuring effective handoffs by clarifying current status and needs to support safe ongoing care. The correct answer, choice A, is the most effective SBAR communication because it provides a concise assessment of breathing and abdominal changes with monitoring recommendations, focusing on potential decompensation. Choice B emphasizes family dynamics, choice C omits symptoms, and choice D mixes components without assessment. The decision-making principle in SBAR communication is to separate components clearly while linking to escalation plans. This enhances handoff accuracy in chronic illness management. A transferable strategy for improving communication skills is to structure handoffs with distinct SBAR sections, practicing in team huddles.
During shift change, the nurse hands off a 77-year-old client with chronic kidney disease and hypertension who is receiving intravenous antibiotics for a bloodstream infection; current assessment shows temperature 39.2 2 0C (102.6 2 0F), blood pressure 90/50 mm Hg, heart rate 120/min, respiratory rate 24/min, oxygen saturation 93% on 2 L nasal cannula, and the client is more confused than baseline. Which statement reflects the nurse's PRIORITY in the SBAR handoff?
Assessment: The client is confused; this is expected in older adults, so no further action is needed.
Background: The client has chronic kidney disease and needs help ordering meals; family plans to visit this evening.
Situation/Assessment: The client has high fever, hypotension, tachycardia, increased respiratory rate, and new confusion while being treated for infection.
Recommendation: Encourage the client to participate in recreational therapy to improve mood.
Explanation
This question tests SBAR communication and clinical judgment during a shift-change handoff for infection management. SBAR is important for ensuring effective handoffs by emphasizing deterioration signs to maintain vigilant monitoring and safety. The correct answer, choice B, is the most effective SBAR communication because it captures the situation and assessment of fever, hypotension, and confusion indicating sepsis progression. Choice A provides non-urgent background, choice C recommends therapy for mood, and choice D dismisses confusion as normal. The decision-making principle in SBAR communication is to prioritize indicators of systemic infection for ongoing assessment. This supports early sepsis recognition in vulnerable clients. A transferable strategy for improving communication skills is to highlight trends in SBAR handoffs, aiding in pattern recognition for infections.
A nurse is transferring a 41-year-old client with sickle cell disease from the medical unit to the step-down unit for closer monitoring; current assessment shows pain 9/10 despite prescribed medication, temperature 38.3 2 0C (100.9 2 0F), heart rate 118/min, blood pressure 110/70 mm Hg, respiratory rate 24/min, and oxygen saturation 90% on room air. What information should the nurse include in the SBAR transfer report?
Recommendation: Plan to review long-term vaccination needs at the next outpatient visit.
Background: The client prefers a warm room and listens to music to relax during painful episodes.
Situation/Assessment: Severe pain with fever, tachycardia, increased respiratory rate, and oxygen saturation 90% on room air; pain not controlled with current regimen.
Situation: The client is being transferred; Background: sickle cell disease; Assessment: the client is uncomfortable; Recommendation: continue usual care.
Explanation
This question tests SBAR communication and clinical judgment during a transfer to step-down unit. SBAR is important for ensuring effective handoffs by communicating pain and vital sign changes to support appropriate monitoring levels. The correct answer, choice A, is the most effective SBAR communication because it provides the situation and assessment of severe pain, fever, and hypoxia indicating a sickle cell crisis complication. Choice B includes room preferences, choice C recommends vaccinations, and choice D is vague without specifics. The decision-making principle in SBAR communication is to detail acute exacerbations for targeted care escalation. This ensures safe transfers in progressive care. A transferable strategy for improving communication skills is to tailor SBAR reports to the receiving unit's focus, emphasizing monitoring needs.