Level: Advanced
Difficulty: Hard
Subtopic: Professional behavior
NCLEX: The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and professio…
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 professional behavior. 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. The new finding that time-sensitive medications are due while one assigned client reports new chest pain.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. 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.