Level: Clinical
Difficulty: Medium
Subtopic: Data accuracy
NCLEX: The telehealth nurse during a virtual follow-up visit is being evaluated for technology-supported nursing care an…
Informatics and healthcare technology Management of Care
Case Study
The telehealth nurse during a virtual follow-up visit is being evaluated for technology-supported nursing care and data accuracy. 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. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Complete nonurgent tasks first because the client appears calm.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: A. 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.