Level: Foundational
Difficulty: Easy
Subtopic: Medication pass safety
NCLEX: A new graduate nurse working with a preceptor is being evaluated for medication pass safety. Assessment data incl…
Professional nursing practice (clinical transition) Management of Care
Case Study
A new graduate nurse working with a preceptor is being evaluated for medication pass safety. Assessment data include simulation data show worsening respiratory distress after the first intervention. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
Rationale
Correct answer: C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.