Level: Advanced
Difficulty: Hard
Subtopic: Interprofessional communication
NCLEX: The RN on a telemetry unit is being evaluated for nursing care related to interprofessional communication. Assess…
Leadership and management Management of Care
Case Study
The RN on a telemetry unit is being evaluated for nursing care related to interprofessional communication. Assessment data include telephone order received for a high-risk IV medication. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.