Level: Clinical
Difficulty: Medium
Subtopic: Scope of practice
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assess…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assessment data include UAP reports the client fell in the bathroom. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.