Level: Clinical
Difficulty: Medium
Subtopic: Insulin and antidiabetics
NCLEX: A 34-year-old client on a telemetry unit is being evaluated for subcutaneous insulin therapy. Assessment data inc…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 34-year-old client on a telemetry unit is being evaluated for subcutaneous insulin therapy. Assessment data include bleeding from the IV site and platelets below the ordered threshold. 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. Tell the client symptoms are expected and avoid notifying the health care team.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
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.