A nurse is assessing a client.
Which of the following factors should the nurse consider?

Choice A rationale
Asking for an order for an incentive spirometer is a recommendation, which belongs in the R step of SBAR. The B step should provide background information about the patient’s condition.
Choice B rationale
Providing the client’s history of sleep apnea is appropriate for the B step, which involves giving background information relevant to the current situation.
Choice C rationale
Describing the client’s current respirations and temperature is part of the Assessment step, not the Background step. The B step should focus on the patient’s medical history and relevant background information.
Choice D rationale
Stating that the client was found unconscious on the floor is part of the Situation step, not the Background step. The B step should provide background information about the patient’s condition.

Choice A rationale
Ignoring the comment and documenting “No Known Allergies” (NKA) is incorrect because it disregards the client’s report of an allergy. This action could lead to potential harm if the client is indeed allergic to codeine.
Choice B rationale
Asking the client why they think it is an allergy is not the best response. It may come across as dismissive and does not provide the nurse with specific information about the client’s allergic reaction.
Choice C rationale
Telling the client not to worry and that they will be okay if they take codeine with food is incorrect. This response is dismissive of the client’s concern and does not address the potential for an allergic reaction.
Choice D rationale
Asking the client what symptoms they experience with codeine is the best response. It allows the nurse to gather specific information about the client’s allergic reaction, which is crucial for safe medication administration.