Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: A 70-year-old client in a rehabilitation facility is being evaluated for high fall risk on a medical unit. Assess…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 70-year-old client in a rehabilitation facility is being evaluated for high fall risk on a medical unit. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which error is most dangerous on the NCLEX and in practice?
Question
A. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: A. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.