Level: Foundational
Difficulty: Easy
Subtopic: Simulation debriefing
NCLEX: A new graduate nurse working with a preceptor is being evaluated for transition-to-practice skills and simulation…
Professional nursing practice (clinical transition) Management of Care
Case Study
A new graduate nurse working with a preceptor is being evaluated for transition-to-practice skills and simulation debriefing. Assessment data include time-sensitive medications are due while one assigned client reports new chest pain. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that time-sensitive medications are due while one assigned client reports new chest pain.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that time-sensitive medications are due while one assigned client reports new chest pain.
Rationale
Correct answer: D. The new finding that time-sensitive medications are due while one assigned client reports new chest pain.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.