A nurse is assessing a client’s understanding of their medication regimen. The client nods in agreement but does not respond verbally. What is the nurse’s best action?

Choice A rationale
Asking the client to demonstrate a skill is part of the evaluation step, not the implementation step. The implementation step involves carrying out the teaching plan, not assessing the client’s ability to perform a skill.
Choice B rationale
Showing the client how to use the incentive spirometer is an appropriate action for the implementation step. This step involves providing education and demonstrating skills to the client.
Choice C rationale
Developing a short-term goal for the client is part of the planning step, not the implementation step. The implementation step involves carrying out the teaching plan, not setting goals.
Choice D rationale
Assessing the client’s pain level is part of the assessment step, not the implementation step. The implementation step involves carrying out the teaching plan, not assessing the client’s condition.

Choice A rationale
The statement “The vital signs are stable” is incorrect for the fifth step of the SBAR communication tool. The fifth step in SBAR is the Recommendation step, where the nurse provides a recommendation or request for what action should be taken next. Stating that the vital signs are stable does not provide a clear recommendation or action plan for the provider to follow.
Choice B rationale
The statement “The client has a history of high blood pressure” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Background step, where the nurse provides relevant clinical background information about the patient’s condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.
Choice C rationale
The statement “The client should be seen by a neurologist” is correct for the fifth step of the SBAR communication tool. In the Recommendation step, the nurse provides a clear and specific recommendation for what action should be taken next. Recommending that the client be seen by a neurologist is an appropriate and actionable recommendation based on the nurse’s assessment.
Choice D rationale
The statement “The client is experiencing severe headaches” is incorrect for the fifth step of the SBAR communication tool. This information belongs in the Assessment step, where the nurse provides an analysis of the patient’s current condition. The Recommendation step should focus on what action the nurse recommends based on the assessment.