# During a shift-change SBAR handoff, the outgoing nurse reports: "Mr. K, 68-year-old male with atrial fibrillation and a UTI, seemed confused a couple of hours ago but is resting comfortably now." Which response by the incoming nurse best demonstrates safe handoff practice?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372684&lang=en  
> language: en  
> subject: Concepts of Management  
> category: MOC

## Question

During a shift-change SBAR handoff, the outgoing nurse reports: "Mr. K, 68-year-old male with atrial fibrillation and a UTI, seemed confused a couple of hours ago but is resting comfortably now." Which response by the incoming nurse best demonstrates safe handoff practice?

## Option

1. Contact the on-call physician without delay to discuss starting stroke protocol due to the reported confusion in this patient with atrial fibrillation.
2. Begin by obtaining a full set of vital signs and performing a neurological check, then ask the outgoing nurse about the confusion later in the shift.
3. Accept the verbal report and the electronic record as accurate, and proceed with the scheduled morning assessments and medication administration.
4. Ask the outgoing nurse to clarify exactly when the confusion began, how long it lasted, and whether any neurological changes were noted. **✔ Correct answer**

**Correct answer: 4**

## Explanation

SBAR requires precise and complete communication. "Seemed confused a couple of hours ago" lacks onset time, duration, and neurological baseline needed for safe clinical continuity. In an older adult with atrial fibrillation, new confusion may represent TIA, stroke, septic encephalopathy, or hypoperfusion. The incoming nurse must clarify ambiguous data before assuming responsibility — this is a patient safety imperative.

## In-depth explanation

Clinical Judgment
Vague handoff language about a potentially time-sensitive neurological change in an AF patient is a red flag. Before any other action, clarify: onset time, duration, neurological exam findings, interventions taken. This is the assessment step applied to handoff.

Memory Tip
AF + New Confusion = TIA/Stroke until ruled out. Vague handoff = unsafe handoff.

KR vs US
Korean handoff often relies on written notes. NCLEX emphasizes verbal clarification of ambiguous clinical data before accepting patient responsibility.

## Clinical scenario

Clinical Practice Guide
TJC National Patient Safety Goal 02.05.01: implement a standardized approach to handoff communication, including an opportunity for questions. SBAR is the gold standard — all four components must be complete before the incoming nurse accepts responsibility.

Caution
NCLEX handoff questions test whether the nurse asks the RIGHT clarifying question. The time course of a neurological change is the missing safety-critical information.

## Key concepts

- **SBAR** — Structured communication tool: Situation, Background, Assessment, Recommendation. TJC-adopted handoff standard. All 4 components must be complete for a safe handoff.
- **Atrial Fibrillation** — Irregular heart rhythm from chaotic atrial electrical activity. Five-fold increased stroke risk from clot formation. NCLEX: new neurological changes in AF patients should be treated as cardioembolic TIA/stroke until ruled out.
- **TIA (Transient Ischemic Attack)** — Focal neurological symptoms lasting minutes to hours with full recovery and no permanent damage. Warning sign for stroke. NCLEX: 10–15% stroke risk within 90 days after TIA; requires immediate neurological evaluation.

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