# A nurse prepares an SBAR call about postoperative deterioration. For this exercise, Situation identifies the immediate problem, Background supplies established preceding context, Assessment interprets combined findings, and Recommendation requests the next action. Classify each single-function message once. Categories may contain multiple messages and have no fixed totals.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=569394&lang=en  
> language: en  
> subject: Collaboration with Multidisciplinary Team  
> category: MOC

## Question

A nurse prepares an SBAR call about postoperative deterioration. For this exercise, Situation identifies the immediate problem, Background supplies established preceding context, Assessment interprets combined findings, and Recommendation requests the next action. Classify each single-function message once. Categories may contain multiple messages and have no fixed totals.

**1.** The client in room 412 has developed new confusion and a BP of 86/50 mm Hg during this hour.

Select a category
Situation
Assessment
Background
Recommendation

**2.** Abdominal surgery was completed yesterday, and the client received the scheduled postoperative anticoagulant this morning.

Select a category
Situation
Assessment
Background
Recommendation

**3.** The pressure decline together with increasing bloody drain output is more consistent with ongoing blood loss than isolated medication sedation.

Select a category
Situation
Assessment
Background
Recommendation

**4.** Please assess the client at the bedside immediately.

Select a category
Situation
Assessment
Background
Recommendation

**5.** The immediate concern prompting this call is rapidly worsening circulatory status.

Select a category
Situation
Assessment
Background
Recommendation

**6.** Before this change, the client was alert with BP 124/76 mm Hg and only a small amount of serosanguineous drainage.

Select a category
Situation
Assessment
Background
Recommendation

**7.** The combination of confusion and reduced urine output indicates impaired organ perfusion despite the absence of reported pain.

Select a category
Situation
Assessment
Background
Recommendation

**8.** Please provide orders for urgent blood sampling and the resuscitation plan while the bedside review is arranged.

Select a category
Situation
Assessment
Background
Recommendation

## Explanation

Situation: messages 1 and 5. Background: 2 and 6. Assessment: 3 and 7. Recommendation: 4 and 8. The time relationship separates prior baseline from the present problem. Interpretation connects findings into a clinical concern, while requests specify what help or orders are needed next. The exercise states its convention to avoid disputed classification of isolated vital signs.

## In-depth explanation

Correct answer
Situation: messages 1 and 5. Background: 2 and 6. Assessment: 3 and 7. Recommendation: 4 and 8.

Why this is correct
The time relationship separates prior baseline from the present problem. Interpretation connects findings into a clinical concern, while requests specify what help or orders are needed next. The exercise states its convention to avoid disputed classification of isolated vital signs.

Clinical picture
A deteriorating client requires immediate escalation under local emergency procedures. Organizing the call should improve communication, not postpone bedside stabilization or the request for help.

Memory hook
Now, before, meaning, next: locate each message in the communication task. A number alone does not determine its category.

NCLEX decision rule
Keep each message to one communication function when a task requires exclusive classification. A real handoff may combine functions, but then forcing one label without context is inappropriate.

Why the alternatives are wrong
Messages 1 and 5 communicate what is happening now, not a request for a specific intervention. Message 2 supplies preceding treatment and surgical context. Message 6 is a comparison baseline, even though it contains vital signs. Messages 3 and 7 interpret patterns and consequences, so they are not merely observations. Messages 4 and 8 specify requested actions rather than adding another diagnostic conclusion. Equal category sizes in this one item are incidental and are not shown as learner-facing quotas. The clinical meaning of each message determines the answer.

Sources
AHRQ TeamSTEPPS SBAR

## Clinical scenario

Practice transfer: A deteriorating client requires immediate escalation under local emergency procedures. Organizing the call should improve communication, not postpone bedside stabilization or the request for help.

## Key concepts

- **SBAR** — A structured framework for situation, background, assessment and recommendation.
- **Clinical interpretation** — Connecting findings to a reasoned account of the likely problem.
- **Escalation** — Seeking additional assessment or support as patient risk increases.

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