Level: Clinical
Difficulty: Medium
Subtopic: Privacy and cybersecurity
NCLEX: The RN using the electronic health record is being evaluated for technology-supported nursing care and privacy an…
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 privacy and cybersecurity. Assessment data include alarm fatigue is reported after repeated nonactionable monitor alarms overnight. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: B. 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.