Level: Foundational
Difficulty: Easy
Subtopic: Delegation to assistive personnel
NCLEX: The nurse manager during a busy day shift is being evaluated for nursing care related to delegation to assistive…
Leadership and management Management of Care
Case Study
The nurse manager during a busy day shift is being evaluated for nursing care related to delegation to assistive personnel. Assessment data include telephone order received for a high-risk IV medication. 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 telephone order received for a high-risk IV medication.
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 telephone order received for a high-risk IV medication.
Rationale
Correct answer: D. The new finding that telephone order received for a high-risk IV medication.
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.