# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397242&lang=en  
> language: en  
> subject: Client Rights  
> category: MOC

## 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?

## Option

1. I think the client needs immediate evaluation for possible shock. **✔ Correct answer**
2. The client was admitted yesterday with pneumonia.
3. The client has an IV in the left forearm.
4. The blood pressure is 86/48 mm Hg and urine output is 15 mL/hr.

**Correct answer: 1**

## 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.

## In-depth explanation

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.

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