Level: Clinical
Difficulty: Medium
Subtopic: Telehealth nursing
NCLEX: The RN using the electronic health record is being evaluated for technology-supported nursing care and telehealth…
Informatics and healthcare technology Management of Care
Case Study
The RN using the electronic health record is being evaluated for technology-supported nursing care and telehealth nursing. Assessment data include the barcode scanner displays a medication-client mismatch at the bedside. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.