Level: Clinical
Difficulty: Medium
Subtopic: Medication pass safety
NCLEX: A senior nursing student during a supervised medication pass is being evaluated for medication pass safety. Asses…
Professional nursing practice (clinical transition) Management of Care
Case Study
A senior nursing student during a supervised medication pass is being evaluated for medication pass safety. Assessment data include time-sensitive medications are due while one assigned client reports new chest pain. 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. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. 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.