Level: Advanced
Difficulty: Hard
Subtopic: Home health safety
NCLEX: The school nurse during a vaccination clinic is being evaluated for community health nursing and home health safe…
Community / public health nursing Health Promotion and Maintenance
Case Study
The school nurse during a vaccination clinic is being evaluated for community health nursing and home health safety. Assessment data include a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Document the finding and recheck at the end of the shift without further assessment.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Document the finding and recheck at the end of the shift without further assessment.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.