Level: Clinical
Difficulty: Medium
Subtopic: Scope of practice
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to scope of practice….
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to scope of practice. Assessment data include new chest pain rated 8/10 with diaphoresis. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that new chest pain rated 8/10 with diaphoresis.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that new chest pain rated 8/10 with diaphoresis.
Rationale
Correct answer: D. The new finding that new chest pain rated 8/10 with diaphoresis.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.