Level: Advanced
Difficulty: Hard
Subtopic: Interprofessional communication
NCLEX: The nurse manager during a busy day shift is being evaluated for nursing care related to interprofessional commun…
Leadership and management Management of Care
Case Study
The nurse manager during a busy day shift is being evaluated for nursing care related to interprofessional communication. Assessment data include new chest pain rated 8/10 with diaphoresis. 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. Administer the next scheduled intervention before reassessing the client.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
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.