Level: Foundational
Difficulty: Easy
Subtopic: Simulation debriefing
NCLEX: The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and simulatio…
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 simulation debriefing. Assessment data include the preceptor stops a medication pass because the student did not verify two identifiers. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: B. 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.