Level: Foundational
Difficulty: Easy
Subtopic: Pre-clinical preparation
NCLEX: A new graduate nurse working with a preceptor is being evaluated for transition-to-practice skills and pre-clinic…
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 pre-clinical preparation. Assessment data include the new graduate feels unsure about an order that conflicts with the allergy list. 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. Administer the next scheduled intervention before reassessing the client.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Administer the next scheduled intervention before reassessing the client.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.