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 smart pump hard stop appears for an infusion rate outside the safe range. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale
Correct answer: D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.