Level: Clinical
Difficulty: Medium
Subtopic: Gastrointestinal disorders
NCLEX: A 45-year-old client in the emergency department is being evaluated for partial bowel obstruction. Assessment dat…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for partial bowel obstruction. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which action is appropriate within the RN scope of practice?
Question
A. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
B. Independently diagnose the medical disease and prescribe treatment.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
B. Independently diagnose the medical disease and prescribe treatment.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
Rationale
Correct answer: A. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.