Level: Foundational
Difficulty: Easy
Subtopic: Barcode medication administration
NCLEX: The telehealth nurse during a virtual follow-up visit is being evaluated for barcode medication administration. A…
Informatics and healthcare technology Management of Care
Case Study
The telehealth nurse during a virtual follow-up visit is being evaluated for barcode medication administration. Assessment data include alarm fatigue is reported after repeated nonactionable monitor alarms overnight. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: B. 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.