Level: Advanced
Difficulty: Hard
Subtopic: Translating evidence into practice
NCLEX: The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and translating ev…
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 translating evidence into practice. Assessment data include fall rates increased from 2.1 to 4.8 per 1,000 patient days after a process change. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: B. 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.