Level: Clinical
Difficulty: Medium
Subtopic: Change management
NCLEX: The charge nurse on a medical-surgical unit is being evaluated for nursing care related to change management. Ass…
Leadership and management Management of Care
Case Study
The charge nurse on a medical-surgical unit is being evaluated for nursing care related to change management. Assessment data include telephone order received for a high-risk IV medication. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.