Nclexrn Quiz: Communication And Handoff Sbar
20 questions · exam conditions
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Communication And Handoff SbarQuestion 1 of 20

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?

Request an order to increase oxygen delivery and evaluate for respiratory support due to worsening hypoxia and increased work of breathing.
Ask whether the client can have a regular diet and if physical therapy can start today to prevent deconditioning.
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.
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Nclexrn Quiz: Communication And Handoff Sbar

Practice Communication And Handoff Sbar in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Communication And Handoff Sbar, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

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?

  1. Request an order to increase oxygen delivery and evaluate for respiratory support due to worsening hypoxia and increased work of breathing. (correct answer)
  2. Ask whether the client can have a regular diet and if physical therapy can start today to prevent deconditioning.
  3. Report that the client has been hospitalized twice this year and prefers to sleep in a recliner at home.
  4. 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.

Question 2

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?

  1. 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. (correct answer)
  2. Background: The client enjoys gardening, has two adult children, and prefers not to receive visitors during the day.
  3. Recommendation: Plan to discuss long-term fall-prevention strategies and arrange a home safety evaluation after discharge.
  4. Assessment: The client is stable for transport; no need to mention anticoagulant use because it is listed in the chart.
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.

Question 3

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?

  1. Situation/Background: The client has a seizure history and missed the morning seizure medication; current vital signs are stable and the client is alert. (correct answer)
  2. Background: The clients favorite music helps with relaxation; request that staff play it during the scan.
  3. Recommendation: Ask imaging staff to provide detailed teaching on seizure management after discharge.
  4. Assessment: The client is stable; omit missed medication because it is not relevant to the scan.
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.

Question 4

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?

  1. Request an order for urinary catheterization or a specific protocol to relieve acute urinary retention. (correct answer)
  2. Request that the client be scheduled for nutrition counseling to reduce evening fluid intake long term.
  3. Recommend waiting until morning rounds because urinary retention often resolves overnight.
  4. Recommend encouraging the client to drink more fluids to stimulate urination without addressing bladder volume.
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.

Question 5

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?

  1. 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. (correct answer)
  2. Background: The client is worried about returning to work and would like information about cardiac-healthy recipes.
  3. Recommendation: Encourage walking in the hallway every hour to prevent constipation.
  4. Situation: The groin looks different; Background: the client had a catheterization; Assessment: the nurse thinks it is probably normal bruising.
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.

Question 6

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?

  1. Request immediate evaluation and orders for oxygen support and treatment for acute breathing difficulty based on severe hypoxia and lung crackles. (correct answer)
  2. Request an order for a stool softener because the client has not had a bowel movement today.
  3. Recommend limiting fluids for the next month and scheduling a follow-up appointment after discharge.
  4. Recommend waiting to reassess after the client rests because anxiety can cause shortness of breath.
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.

Question 7

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?

  1. Provide a concise assessment of breathing status and abdominal changes and include what monitoring or provider notification is needed if symptoms worsen. (correct answer)
  2. Include a detailed description of the clients family dynamics and coping style as the main focus.
  3. Focus only on background liver history and omit current symptoms because they may fluctuate.
  4. Mix situation and recommendation by stating, He needs a procedure today, without providing current assessment findings.
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.

Question 8

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°C (102.6°F), 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?

  1. Background: The client has chronic kidney disease and needs help ordering meals; family plans to visit this evening.
  2. Situation/Assessment: The client has high fever, hypotension, tachycardia, increased respiratory rate, and new confusion while being treated for infection. (correct answer)
  3. Recommendation: Encourage the client to participate in recreational therapy to improve mood.
  4. Assessment: The client is confused; this is expected in older adults, so no further action is needed.
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.

Question 9

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°C (100.9°F), 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?

  1. Situation/Assessment: Severe pain with fever, tachycardia, increased respiratory rate, and oxygen saturation 90% on room air; pain not controlled with current regimen. (correct answer)
  2. Background: The client prefers a warm room and listens to music to relax during painful episodes.
  3. Recommendation: Plan to review long-term vaccination needs at the next outpatient visit.
  4. 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.

Question 10

At an interdisciplinary team meeting in an inpatient rehabilitation unit, the nurse uses SBAR to update the team on a 81-year-old client with a recent stroke and a history of atrial fibrillation; current assessment shows blood pressure 150/86 mm Hg, heart rate 92/min irregular, coughing with thin liquids, and new wet-sounding voice after meals. The nurse should focus on which aspect of SBAR to ensure effective communication?

  1. Recommendation: Request a swallow evaluation and diet modification due to signs of aspiration during meals. (correct answer)
  2. Background: Provide a detailed timeline of the client's entire medical history since childhood.
  3. Situation: Emphasize that the family is upset about therapy scheduling as the main concern.
  4. Assessment: State only that the client is "fine for rehab" without describing current swallowing findings.
Explanation: This question tests SBAR communication and clinical judgment in a rehabilitation team meeting. SBAR is important for ensuring effective handoffs by integrating nursing insights into team plans for holistic client safety. The correct answer, choice A, is the most effective SBAR communication because it recommends a swallow evaluation for aspiration risks like coughing and wet voice, addressing immediate safety concerns. Choice B provides excessive historical background, choice C emphasizes family scheduling over clinical issues, and choice D vaguely states stability without details. The decision-making principle in SBAR communication is to recommend evidence-based actions based on assessment to prevent complications like pneumonia. This enhances team collaboration in rehab settings. A transferable strategy for improving communication skills is to contribute SBAR updates in meetings, emphasizing recommendations tied to safety risks.

Question 11

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?

  1. Request orders to keep the client nothing by mouth until evaluated and to obtain a swallow evaluation due to aspiration risk. (correct answer)
  2. Request a change to the nighttime sleep routine to help the client rest longer and to improve energy during daytime meals.
  3. Ask for a referral to social work to discuss transportation after discharge and to arrange home care support for the client's family.
  4. Recommend continuing the current diet with thickened liquids because coughing is common in Parkinson disease and is managed with position changes.
Explanation: Calling the provider about a client with new coughing during meals, drooling, coarse breath sounds, and oxygen saturation 92% requires an immediate focus on airway safety. The best SBAR recommendation is to keep the client nothing by mouth until a swallow evaluation is completed and to obtain that evaluation, because these findings suggest aspiration risk. Changing the nighttime sleep routine might support rest but does not address the urgent swallowing problem or the oxygen desaturation. A social work referral for transportation after discharge is part of discharge planning, not the priority for this acute change. Recommending thickened liquids while continuing the diet presumes a safe swallowing strategy without a formal evaluation; it overlooks the aspiration warning signs and could permit further aspiration. The nurse's most important communication must therefore be a clear protective recommendation, not a lower-priority or untested dietary adjustment.

Question 12

During shift change, the outgoing nurse reports on a 26-year-old client with no significant medical history who is 4 hours after an appendectomy; current assessment shows temperature 37.9°C (100.2°F), heart rate 102/min, blood pressure 124/78 mm Hg, pain 7/10, and the client has not voided since surgery with a bladder scan of 620 mL. What is the MOST important recommendation for the nurse to communicate using SBAR to the incoming nurse?

  1. Recommend assessing for urinary retention and implementing ordered interventions (assist to void, notify provider per protocol if unable). (correct answer)
  2. Recommend discussing long-term exercise goals and returning to work planning.
  3. Recommend postponing any action until the next scheduled rounding time to reduce interruptions.
  4. Recommend focusing on teaching incision care and bathing instructions before addressing voiding.
Explanation: This question tests SBAR communication and clinical judgment during a post-operative shift-change handoff. SBAR is important for ensuring effective handoffs by highlighting post-surgical risks to maintain vigilant monitoring and safety. The correct answer, choice A, is the most effective SBAR communication because it recommends assessing and intervening for urinary retention based on bladder scan and symptoms, preventing complications like infection. Choice B focuses on long-term goals, choice C suggests postponing action, and choice D prioritizes teaching over voiding issues. The decision-making principle in SBAR communication is to recommend protocol-driven actions for common post-op issues like retention. This supports timely resolution and client comfort. A transferable strategy for improving communication skills is to use SBAR in handoffs to clearly outline recommendations for post-surgical care priorities.

Question 13

During an interdisciplinary team meeting on a medical-surgical unit, the nurse provides an SBAR update on a 62-year-old client with type 2 diabetes and peripheral neuropathy admitted for a foot ulcer; current assessment shows temperature 38.1°C (100.6°F), heart rate 102/min, blood pressure 132/78 mm Hg, blood glucose 286 mg/dL, increasing redness around the ulcer, and pain 5/10. The nurse should focus on which aspect of SBAR to ensure effective communication?

  1. Emphasize the clients preferred meal choices and cultural food practices to improve satisfaction scores.
  2. Provide a clear recommendation for next steps, such as notifying the provider about possible worsening infection and need for wound and glucose management adjustments. (correct answer)
  3. List all medications the client has ever taken for diabetes without summarizing current concerns.
  4. Describe the situation using only general terms ("not doing well") to avoid alarming the team.
Explanation: This question tests SBAR communication and clinical judgment in an interdisciplinary team meeting. SBAR is important for ensuring effective handoffs by facilitating collaborative discussions that enhance client safety through shared understanding of priorities. The correct answer, choice B, is the most effective SBAR communication because it emphasizes a clear recommendation for addressing worsening infection and glucose control, guiding team actions toward urgent interventions. Choice A focuses on meal preferences for satisfaction, choice C lists medications without linking to current issues, and choice D uses vague terms that fail to convey the severity of the situation. The decision-making principle in SBAR communication is to provide specific recommendations tied to assessment findings to drive focused team responses. This promotes efficient problem-solving in multidisciplinary settings. A transferable strategy for improving communication skills is to prepare SBAR summaries before meetings, highlighting key recommendations to foster productive discussions.

Question 14

A nurse in a community clinic must call the provider using SBAR about a 29-year-old client who is 10 days postpartum with a history of preeclampsia. Current assessment: blood pressure 168/110 mm Hg, heart rate 92/min, respiratory rate 18/min, temperature 36.9°C (98.4°F); the client reports a severe headache and blurred vision. Which statement reflects the nurse's PRIORITY in the SBAR communication?

  1. "The client is breastfeeding and would like to know which over-the-counter cold medicines are safe to take."
  2. "The client is 10 days postpartum with a history of preeclampsia and now has blood pressure 168/110 with severe headache and blurred vision; I recommend immediate evaluation for postpartum hypertension complications and orders for urgent treatment." (correct answer)
  3. "The client is tired from newborn care and is requesting a note for family leave from work."
  4. "The client's prenatal course included nausea in the first trimester and mild swelling near the end of pregnancy."
Explanation: This question tests SBAR communication and clinical judgment in recognizing postpartum preeclampsia as a medical emergency. SBAR is essential for ensuring effective handoffs and client safety by communicating urgent situations requiring immediate intervention. Option B is the most effective SBAR communication because it clearly identifies the situation (postpartum with preeclampsia history), current critical findings (severe hypertension, neurological symptoms), and specific recommendation for urgent treatment of a potentially life-threatening complication. Option A addresses a routine education need, option C focuses on fatigue rather than medical concerns, and option D provides irrelevant historical information. The decision-making principle is that SBAR communication must convey urgency when presenting findings consistent with medical emergencies, particularly postpartum complications that can rapidly deteriorate. To improve emergency communication, use clear, direct language that emphasizes the severity of findings and the need for immediate action.

Question 15

A nurse on a medical-surgical unit notes an acute change in condition and needs to call the healthcare provider using SBAR. The client is a 74-year-old with chronic obstructive pulmonary disease and heart failure admitted for pneumonia; current assessment: temperature 38.3°C (100.9°F), heart rate 118/min, blood pressure 156/88 mm Hg, respiratory rate 30/min, oxygen saturation 86% on 4 L/min nasal cannula; the client is using accessory muscles and is anxious. What is the MOST IMPORTANT recommendation for the nurse to communicate using SBAR?

  1. Request an order to increase oxygen and evaluate the client now due to worsening respiratory distress and oxygen saturation 86% on 4 L/min nasal cannula. (correct answer)
  2. Ask whether the client can have a sleep medication because the client is anxious and has not rested well.
  3. Report that the client has a history of heart failure and chronic obstructive pulmonary disease and was admitted yesterday for pneumonia.
  4. Recommend encouraging oral fluids and ambulation later today to help loosen secretions.
Explanation: This question tests SBAR communication and clinical judgment in formulating appropriate recommendations during provider notification. SBAR is essential for ensuring effective handoffs and client safety by structuring communication to facilitate rapid decision-making. Option A is the most effective SBAR communication because it provides a clear, action-oriented recommendation that addresses the client's critical respiratory distress with specific interventions needed (increase oxygen, immediate evaluation). Option B focuses on a comfort measure rather than the urgent respiratory crisis, option C provides background information without addressing the current acute change, and option D suggests routine interventions inappropriate for a client in respiratory distress. The decision-making principle is that the Recommendation component of SBAR should provide specific, actionable requests that directly address the identified problem. To improve SBAR communication skills, practice formulating clear recommendations that include both the intervention needed and the urgency of the situation.

Question 16

A home health nurse calls the provider about a 67-year-old client with heart failure and chronic hypertension; current assessment shows weight up 2.7 kg (6 lb) in 3 days, new bilateral ankle swelling, shortness of breath with minimal activity, blood pressure 160/92 mm Hg, heart rate 96/min, and oxygen saturation 91% on room air. What is the MOST important recommendation for the nurse to communicate using SBAR?

  1. Request guidance on adjusting diuretic therapy and need for urgent evaluation due to rapid weight gain, swelling, and worsening shortness of breath. (correct answer)
  2. Ask for a referral to a community exercise class to improve endurance over the next month.
  3. Discuss the clients favorite low-sodium foods and ask for a diet plan for the next year.
  4. Recommend waiting one week to recheck weight because daily weights can cause anxiety.
Explanation: This question tests SBAR communication and clinical judgment in a home health setting when calling a provider. SBAR is important for ensuring effective handoffs by structuring remote reports to convey urgency and support safe community-based care. The correct answer, choice A, is the most effective SBAR communication because it recommends adjusting therapy and urgent evaluation for signs of heart failure exacerbation like weight gain and shortness of breath. Choice B suggests long-term exercise referral, choice C discusses food preferences, and choice D recommends delaying weight checks, all overlooking immediate needs. The decision-making principle in SBAR communication is to link recommendations to acute assessment changes for timely management. This is crucial in non-hospital settings where delays can worsen outcomes. A transferable strategy for improving communication skills is to log SBAR calls and review them for effectiveness in advocating for client needs remotely.

Question 17

A nurse is transferring a 70-year-old client with chronic kidney disease and hypertension to the intensive care unit due to worsening condition; current assessment shows blood pressure 78/46 mm Hg, heart rate 122/min, respiratory rate 26/min, oxygen saturation 92% on 4 L nasal cannula, cool clammy skin, and urine output 10 mL in the last hour. Which statement reflects the nurse's PRIORITY in the SBAR transfer report?

  1. Background: The client has been married for 45 years and prefers to have the television on low volume at night.
  2. Situation/Assessment: The client is hypotensive with tachycardia, low urine output, and signs of poor perfusion despite oxygen support. (correct answer)
  3. Recommendation: Request a chaplain visit and discuss advanced directives when the family arrives.
  4. Assessment: The client is tired and has not eaten much today; provide a full dietary recall from the past week.
Explanation: This question tests SBAR communication and clinical judgment in a transfer to intensive care. SBAR is important for ensuring effective handoffs by conveying critical status changes to prepare the receiving team for immediate care needs. The correct answer, choice B, is the most effective SBAR communication because it prioritizes the situation and assessment of hypotension, tachycardia, and low urine output suggesting poor perfusion, which are urgent for ICU management. Choice A includes non-priority background on marriage and TV preferences, choice C recommends spiritual support unrelated to acute issues, and choice D provides vague assessment with unnecessary dietary details. The decision-making principle in SBAR communication is to highlight signs of instability to guide intensive monitoring and interventions. This supports safe transitions in escalating care levels. A transferable strategy for improving communication skills is to review SBAR reports post-transfer for completeness, refining focus on priorities over time.

Question 18

A nurse is transferring a 72-year-old client with a history of chronic obstructive pulmonary disease from the medical unit to the operating room for an urgent procedure; current assessment shows oxygen saturation 88% on 3 L nasal cannula, respiratory rate 28/min, heart rate 112/min, and the client is anxious and using accessory muscles. What information should the nurse include in the SBAR report to the receiving team?

  1. Situation/Assessment: The client has chronic lung disease with current increased work of breathing and oxygen saturation 88% on 3 L nasal cannula, respiratory rate 28/min, and heart rate 112/min. (correct answer)
  2. Background: The client quit smoking 10 years ago and prefers a specific brand of nicotine gum.
  3. Recommendation: Discuss long-term pulmonary rehabilitation options after the surgery is completed.
  4. Assessment: The client is anxious; do not mention oxygen flow rate because it can be adjusted later.
Explanation: This question tests SBAR communication and clinical judgment during a transfer to the operating room. SBAR is important for ensuring effective handoffs by informing perioperative teams of respiratory risks to optimize safety. The correct answer, choice A, is the most effective SBAR communication because it details the situation and assessment of hypoxia, increased work of breathing, and anxiety in a COPD client, alerting to potential complications. Choice B provides smoking history and gum preferences, choice C recommends post-op rehab, and choice D omits oxygen details. The decision-making principle in SBAR communication is to include current respiratory status for pre-procedure preparation. This supports safe anesthesia management. A transferable strategy for improving communication skills is to customize SBAR for transfers, highlighting system-specific risks like respiratory.

Question 19

A nurse calls the healthcare provider about a 33-year-old client with asthma admitted for an exacerbation; current assessment shows the client is speaking in short phrases, respiratory rate 34/min, oxygen saturation 88% on room air, heart rate 128/min, and use of accessory muscles after two prescribed breathing treatments. What information should the nurse include in the SBAR report?

  1. Situation/Assessment: The client has worsening shortness of breath with oxygen saturation 88% on room air, respiratory rate 34/min, heart rate 128/min, accessory muscle use, and minimal response after two treatments. (correct answer)
  2. Background: The client was diagnosed with asthma as a teenager and works as a teacher; family is at the bedside.
  3. Recommendation: Ask if the client can be discharged later today if symptoms improve after rest.
  4. Assessment: The client is anxious; omit objective findings because the provider can review them in the electronic record.
Explanation: This question tests SBAR communication and clinical judgment when calling a provider about an asthma exacerbation. SBAR is important for ensuring effective handoffs by organizing urgent data to support timely medical decisions and client safety. The correct answer, choice A, is the most effective SBAR communication because it details the situation and assessment of worsening symptoms like low saturation and accessory muscle use despite treatments, indicating respiratory distress. Choice B provides irrelevant background on diagnosis and work, choice C recommends premature discharge planning, and choice D omits objective data, relying on electronic records. The decision-making principle in SBAR communication is to include comprehensive assessment details to inform provider interventions accurately. This facilitates rapid escalation in acute respiratory cases. A transferable strategy for improving communication skills is to use SBAR templates for provider calls, ensuring all components are addressed systematically.

Question 20

A nurse is giving shift-change handoff for a 45-year-old client with obesity and obstructive sleep apnea who is 12 hours after gallbladder removal; current assessment shows respiratory rate 10/min, oxygen saturation 89% on 2 L nasal cannula, difficult to arouse, and last opioid pain medication given 30 minutes ago. What is the MOST important recommendation for the nurse to communicate using SBAR to the incoming nurse?

  1. Recommend immediate assessment for opioid-related respiratory depression and escalation per protocol (stimulate, increase monitoring, notify provider/rapid response as indicated). (correct answer)
  2. Recommend delaying vital signs until the client is fully awake to avoid disturbing rest.
  3. Recommend focusing on teaching about diet changes after gallbladder removal before discharge.
  4. Recommend documenting the clients preference for a quiet room and limiting visitors.
Explanation: This question tests SBAR communication and clinical judgment during a shift-change handoff for a post-operative client. SBAR is important for ensuring effective handoffs by structuring reports to highlight risks and maintain continuity of safe care. The correct answer, choice A, is the most effective SBAR communication because it recommends immediate assessment and escalation for opioid-induced respiratory depression, addressing the critical low respiratory rate and saturation. Choice B suggests delaying vital signs, choice C focuses on diet teaching, and choice D prioritizes room preferences, all ignoring the urgent respiratory issue. The decision-making principle in SBAR communication is to recommend protocol-based actions for acute changes to prevent adverse outcomes. This ensures the incoming nurse can act swiftly on potential complications. A transferable strategy for improving communication skills is to incorporate SBAR into daily handoffs, practicing emphasis on recommendations for high-risk scenarios.