Level: Clinical
Difficulty: Medium
Subtopic: Quality improvement indicators
NCLEX: The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and quality improv…
Statistics or evidence-based practice Management of Care
Case Study
The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and quality improvement indicators. Assessment data include fall rates increased from 2.1 to 4.8 per 1,000 patient days after a process change. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.