How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is using the situation, background, assessment, recommendation (SBAR) format to provide a hand-off report for a client. In which of the following components of the SBAR report should the nurse include information about the client's current vital signs?

A.

Situation

B.

Background

C.

Assessment

D.

Recommendation

Answer and Explanation

The Correct Answer is C

Rationale:

A. This option is incorrect because the "Situation" component of SBAR is used to provide a brief statement of the client’s current problem or reason for the report. It identifies the issue but does not include detailed clinical data such as vital signs.

B. This option is incorrect because the "Background" section includes relevant past medical history, recent lab results, medications, or procedures that provide context for the client’s current condition. While important for context, it does not typically include the immediate vital signs.

C. This option is correct because the "Assessment" component of SBAR is where the nurse communicates clinical findings, including current vital signs, physical assessment results, and any changes in condition. This information helps the receiving nurse or provider understand the client’s present status and determine appropriate next steps.

D. This option is incorrect because the "Recommendation" section is used to suggest actions, interventions, or further orders for the client. It communicates what the nurse believes should be done but does not include objective data such as vital signs.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["A","E","H"]

Explanation

Rationale

Autonomy

  • Informed consent obtained by provider and verified by nurse: Supports the client’s right to make informed decisions about their own care.

Fidelity

  • Client provided with additional information about recovery as promised at last visit: Demonstrates keeping commitments and being faithful to what was promised to the client.

Nonmaleficence

  • Evidence-based standards of postoperative care reviewed with nursing staff prior to procedure: Reflects the obligation to do no harm by providing safe, evidence-based care to prevent complications.

Findings not selected

  • Provider prescriptions for a mammogram and ultrasound of the breasts: Reflects medical decision-making, not autonomy.
  • Client reassured that medical records remain confidential: Corresponds more closely with confidentiality, not autonomy.
  • Client reassured that staff will treat all clients equally: Reflects justice, not fidelity.
  • Client states, “I have a bad feeling about this, tell me the truth even if it’s bad news.”: Expresses a desire for truth-telling but does not itself demonstrate fidelity.
  • Documentation of living will and durable power of attorney on client’s chart: Relates to advance directives, not nonmaleficence.
  • Client provided resources for support groups for clients who have diagnosis of cancer: Reflects beneficence, not nonmaleficence.

Correct Answer is D

Explanation

Rationale:

A. This option is incorrect because the decision to have a DNR is made by the client or their legally authorized representative, not solely by the provider. The provider’s role is to discuss options, document the client’s wishes, and write the DNR order.

B. This option is incorrect because a DNR order does not mean the provider will discontinue the client’s medications. A DNR only specifies that cardiopulmonary resuscitation (CPR) should not be performed in the event of cardiac or respiratory arrest; all other medical treatments continue as appropriate.

C. This option is incorrect because the client does not need to sign a separate consent form for CPR if a DNR is not in place. CPR is the default standard of care unless a DNR order is documented.

D. This option is correct because the provider should periodically evaluate the DNR order to ensure it still aligns with the client’s wishes and current health status. Regular review allows for updates if the client’s condition, preferences, or advance directives change.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register