NCLEX-RNManagement of CareMedium
A nurse is transferring care of a client to the oncoming nurse at shift change. Using SBAR format, which information is most important to include in the 'Recommendation' component of the handoff?
- AThe client's most recent vital signs and lab values
- BA specific action the oncoming nurse should take, such as reassessing pain in 30 minutes
- CThe client's admitting diagnosis and past medical history
- DA summary of the client's current condition and level of consciousness
Show answer & explanationAnswer & explanation
Correct answer: B. A specific action the oncoming nurse should take, such as reassessing pain in 30 minutes
In SBAR, the 'Recommendation' component includes specific suggested actions or follow-up needed, such as a time-bound reassessment, so the oncoming nurse knows exactly what to do next. Background information, current vitals/data, and condition summaries belong to the Background and Assessment components, not Recommendation.
Why the other options are wrong
- A. Vital signs and labs are part of the Assessment component.
- C. Admitting diagnosis/history belongs in the Background component.
- D. A condition summary is part of the Assessment, not Recommendation.
SBAR Handoff Communication
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool that ensures continuity of care during handoffs by organizing critical client information.
- Situation: current problem/reason for report
- Background: relevant history and context
- Assessment/Recommendation: current findings and suggested next actions
Memory trick: Situation-Background-Assessment-Recommend: what, why, now, next