Level: Advanced
Difficulty: Hard
Subtopic: Capstone transition
NCLEX: A new graduate nurse working with a preceptor is being evaluated for transition-to-practice skills and capstone t…
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 capstone transition. Assessment data include simulation data show worsening respiratory distress after the first intervention. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale
Correct answer: D. 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.