Level: Clinical
Difficulty: Medium
Subtopic: Mobility and positioning
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to mobility and posi…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to mobility and positioning. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which action is appropriate within the RN scope of practice?
Question
A. Independently diagnose the medical disease and prescribe treatment.
B. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
B. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
Rationale
Correct answer: B. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.