Level: Foundational
Difficulty: Easy
Subtopic: Skills lab checkoff
NCLEX: A senior nursing student during a supervised medication pass is being evaluated for transition-to-practice skills…
Professional nursing practice (clinical transition) Management of Care
Case Study
A senior nursing student during a supervised medication pass is being evaluated for transition-to-practice skills and skills lab checkoff. 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. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: A. 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.