A patient is receiving a new medication. What should the nurse do?

Choice A rationale
Ignoring the comment and documenting “No Known Allergies” (NKA) is incorrect because it disregards the client’s report of an allergy. This action could lead to potential harm if the client is indeed allergic to codeine.
Choice B rationale
Asking the client why they think it is an allergy is not the best response. It may come across as dismissive and does not provide the nurse with specific information about the client’s allergic reaction.
Choice C rationale
Telling the client not to worry and that they will be okay if they take codeine with food is incorrect. This response is dismissive of the client’s concern and does not address the potential for an allergic reaction.
Choice D rationale
Asking the client what symptoms they experience with codeine is the best response. It allows the nurse to gather specific information about the client’s allergic reaction, which is crucial for safe medication administration.

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.