Level: Foundational
Difficulty: Easy
Subtopic: General survey
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for nursing care related to general survey. As…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for nursing care related to general survey. Assessment data include the client reports no sleep and increasing agitation overnight. Which action is appropriate within the RN scope of practice?
Question
A. Independently diagnose the medical disease and prescribe treatment.
B. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
B. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
Rationale
Correct answer: B. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.