Level: Advanced
Difficulty: Hard
Subtopic: Alarm safety
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 alarm safety. Assessment data include a client asks the nurse to send test results to a family member by personal text message. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Tell the client symptoms are expected and avoid notifying the health care team.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Tell the client symptoms are expected and avoid notifying the health care team.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. 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.