A nurse refers a client to a specialist for further evaluation. What level of prevention is this?

Choice A rationale
Calculating intake and output for the unit is a task that can be delegated to an LVN or UAP. It does not require the advanced clinical judgment and skills of an RN.
Choice B rationale
Inserting an NGT (nasogastric tube) for a client who is unable to eat is a task that can be performed by an LVN under the supervision of an RN. While it requires skill, it does not necessarily require the advanced clinical judgment of an RN.
Choice C rationale
Reinforcing teaching with a patient who is learning to walk with a quad cane can be done by an LVN or UAP. This task involves providing support and encouragement, but it does not require the advanced clinical judgment of an RN.
Choice D rationale
An unstable client complaining of feeling faint requires the advanced clinical judgment and skills of an RN. The RN is best equipped to assess the client’s condition, identify potential causes of instability, and implement appropriate interventions to stabilize the client.

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.