Level: Clinical
Difficulty: Medium
Subtopic: Incident reporting
NCLEX: The charge nurse on a medical-surgical unit is being evaluated for nursing care related to incident reporting. As…
Leadership and management Management of Care
Case Study
The charge nurse on a medical-surgical unit is being evaluated for nursing care related to incident reporting. Assessment data include telephone order received for a high-risk IV medication. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that telephone order received for a high-risk IV medication.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. 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.