Level: Clinical
Difficulty: Medium
Subtopic: Patient portals
NCLEX: A bedside nurse using barcode medication administration is being evaluated for technology-supported nursing care…
Informatics and healthcare technology Management of Care
Case Study
A bedside nurse using barcode medication administration is being evaluated for technology-supported nursing care and patient portals. 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. Document the client as stable without reassessment.
C. Document the finding and recheck at the end of the shift without further assessment.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Document the finding and recheck at the end of the shift without further assessment.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.