# A nurse gives an SBAR handoff for a client admitted with sepsis from a urinary tract infection. Which statements correctly describe SBAR components? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368306&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: MOC

## Question

A nurse gives an SBAR handoff for a client admitted with sepsis from a urinary tract infection. Which statements correctly describe SBAR components? Select all that apply.

1

Background is a complete chronological narrative of the hospitalization, including the full medication history and vital-sign sets from previous shifts

2

Recommendation is left out of the report because the nurse reports assessment data but leaves proposed next steps to the receiving clinician

3

Situation briefly identifies the client and states the immediate reason for the report, such as a new blood pressure decline during treatment for sepsis

4

Assessment communicates the nurse's clinical interpretation of the current problem and supports it with relevant findings and trends

5

Situation begins with a detailed review of past medical and social history before the nurse states the acute concern that prompted the report

6

Client identifiers are omitted from a care-team handoff because using a name, room, or medical record number for treatment communication violates HIPAA

## Explanation

SBAR organizes a focused handoff as Situation, Background, Assessment, and Recommendation. Situation identifies the client and immediate concern (Choice 3). Assessment states the nurse's interpretation supported by pertinent findings and trends (Choice 4). Background includes relevant context rather than a complete flow-sheet narrative (Choice 1). Recommendation communicates the action, response, or follow-up the nurse believes is needed within the nurse's role (Choice 2). Situation should state the acute concern before relevant history (Choice 5). Appropriate identifiers may be used for treatment communication among the care team while privacy safeguards are maintained (Choice 6).

## In-depth explanation

SBAR Components
1. S — Situation: one line of WHO + WHERE + WHAT now. "Mr. X, room 412, sepsis from UTI, BP 88/52 trending down."
2. B — Background: targeted relevant context — admission diagnosis, code status, allergies, recent significant events, current critical treatments
3. A — Assessment: nurse's clinical interpretation supported by data + trends ("I'm worried about septic shock vs volume depletion")
4. R — Recommendation: explicit ask — "Recommend transfer to ICU and 30 mL/kg crystalloid bolus; please come evaluate"

Hand-off Best Practices
- Use the SBAR framework consistently
- Face-to-face if possible; structured form/template
- Read-back of critical information
- Bedside hand-off with the client when feasible
- Limit interruptions; quiet space
- Document the hand-off occurred

Common Hand-off Pitfalls
- Long unfocused PMH at the start (delays urgent issue)
- Complete flow-sheet narrative (drowns the signal)
- Omitting recommendation (loses urgency)
- Vague language ("doing OK")
- Skipping pending tasks

Memory Tip
"S-B-A-R = Situation, Background, Assessment, Recommendation"

## Clinical scenario

Scenario
Adult client admitted yesterday with sepsis from UTI; nurse preparing structured SBAR hand-off to the oncoming nurse.

Sample SBAR
S: "Mr. X, room 412, day 2 of sepsis from UTI, BP trending down to 88/52 over the past hour"
B: code status full, allergies PCN, on Cefepime, has 2L NS in last 6 hr, lactate 3.2
A: "Worried about septic shock vs volume depletion; trending the wrong way despite fluid"
R: "Recommend ICU transfer + 30 mL/kg crystalloid bolus + reassess in 30 min; please come evaluate"

Avoid
- Long PMH first
- Complete flow-sheet narrative
- Omitting Recommendation
- Vague terms

## Key concepts

- **SBAR Hand-off Communication** — Standardized communication framework: Situation (one-line of why this report is occurring), Background (relevant clinical context), Assessment (nurse's clinical interpretation supported by data), Recommendation (explicit ask). Originally developed in the U.S. military and adapted for healthcare to reduce communication errors during transitions of care. Required by The Joint Commission for safe hand-off.
- **Hand-off Best Practices** — Beyond SBAR structure: face-to-face whenever possible, structured form or template, read-back of critical information, bedside hand-off with the client when feasible, limited interruptions in a quiet space, and documentation that hand-off occurred. Address pending tasks, anticipated needs, and current critical issues. Bedside hand-off has been shown to reduce errors and improve client engagement.
- **Nursing Recommendation in Hand-off** — Nurses are expected to make explicit recommendations in SBAR — clinical asks based on assessment (e.g., transfer level of care, additional orders, escalation, anticipated reassessment). The framework was specifically designed to empower the nurse's voice in interdisciplinary communication and during hand-off. "Just data, no opinion" is a common misconception that weakens nursing communication and client safety.

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