Level: Foundational
Difficulty: Easy
Subtopic: Pharmacokinetics
NCLEX: A 34-year-old client on a telemetry unit is being evaluated for a newly prescribed medication regimen. Assessment…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 34-year-old client on a telemetry unit is being evaluated for a newly prescribed medication regimen. Assessment data include the client reports dizziness, blood pressure 92/58 mm Hg, and heart rate 118/min after the morning dose. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.