Level: Foundational
Difficulty: Easy
Subtopic: Skills lab checkoff
NCLEX: The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and skills la…
Professional nursing practice (clinical transition) Management of Care
Case Study
The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and skills lab checkoff. Assessment data include simulation data show worsening respiratory distress after the first intervention. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.