Level: Advanced
Difficulty: Hard
Subtopic: Immune and inflammatory response
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to immune and inflam…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to immune and inflammatory response. Assessment data include the client develops redness and warmth at an IV insertion site. Which action is appropriate within the RN scope of practice?
Question
A. Independently diagnose the medical disease and prescribe treatment.
B. Prescribe new medications without a provider order.
C. Delegate nursing assessment and evaluation on an unstable client.
D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
B. Prescribe new medications without a provider order.
C. Delegate nursing assessment and evaluation on an unstable client.
D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale
Correct answer: D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.