A nurse is giving a handoff report for a client whose blood … | MyMerci
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Question
A nurse is giving a handoff report for a client whose blood pressure is falling and urine output has decreased. Which information should be included in the recommendation portion of SBAR?
1I think the client needs immediate evaluation for possible shock.✓ Correct answer
2The client was admitted yesterday with pneumonia.
3The client has an IV in the left forearm.
4The blood pressure is 86/48 mm Hg and urine output is 15 mL/hr.
Explanation
The recommendation portion of SBAR states what action or response is needed. Falling blood pressure and low urine output suggest poor perfusion, so urgent evaluation is appropriate. Background and assessment data are important but belong in other SBAR sections.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits SBAR recommendation for deterioration.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical scenario
Clinical Practice Guide For SBAR recommendation for deterioration, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
Caution Do not choose an action from one isolated cue when the full scenario changes priority or safety.
Key concepts
SBAR — A structured communication format: situation, background, assessment, recommendation.
Handoff — Transfer of client information and responsibility between clinicians.
Recommendation — The requested next step or action in SBAR communication.