A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B?

Choice A reason: In SBAR (Situation, Background, Assessment, Recommendation), chest pain is part of the Situation (S), describing the current issue. Background (B) includes relevant medical history, like angina, which causes chest pain due to myocardial ischemia from reduced coronary blood flow. Chest pain is the presenting symptom, not historical context, making it incorrect for B.

Choice B reason: Pulse rate of 108 is part of the Assessment (A) in SBAR, reflecting current vital signs. Background (B) provides historical context, such as the patient’s angina diagnosis, which predisposes to myocardial ischemia. Tachycardia may result from pain or hypoxia but is a current finding, not historical data, making it incorrect for B.

Choice C reason: History of angina is the Background (B) in SBAR, providing relevant medical history. Angina, caused by coronary artery narrowing, reduces myocardial oxygen supply, leading to chest pain. This context informs the current episode of pain and tachycardia, guiding assessment and treatment, making it the correct data for the Background component.

Choice D reason: Oxygen is needed is part of the Recommendation (R) in SBAR, suggesting an intervention. Background (B) includes past medical history, like angina, which explains the patient’s predisposition to chest pain. Recommending oxygen addresses current hypoxia but is not historical data, making it inappropriate for the Background section of SBAR.

Choice A reason: Visual acuity measures the clarity of vision, typically tested using a Snellen chart to assess retinal and optic nerve function. Testing cardinal fields of vision evaluates eye muscle coordination, not visual sharpness. This assessment involves cranial nerves III, IV, and VI, not the retina’s ability to resolve fine details, making it irrelevant here.

Choice B reason: Extraocular movements are assessed by testing the cardinal fields of vision, evaluating the coordinated movement of eyes in six directions. This tests cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye muscles. Misalignment or uncoordinated movement may indicate neurological or muscular issues, making this the correct characteristic being assessed.

Choice C reason: Peripheral vision is tested using confrontation tests, assessing the visual field’s outer edges, mediated by retinal rod cells. Cardinal fields of vision testing focuses on eye muscle coordination, not the extent of the visual field. This assessment does not evaluate peripheral retinal function, making peripheral vision an incorrect choice for this procedure.

Choice D reason: Existence of cataracts is assessed via lens opacity examination, often using an ophthalmoscope. Cardinal fields of vision testing evaluates eye movement coordination, not lens clarity. Cataracts impair light transmission to the retina, but this test targets extraocular muscle function and cranial nerve integrity, making cataract assessment irrelevant to this procedure.