Level: Clinical
Difficulty: Medium
Subtopic: Clinical communication
NCLEX: The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and clinical…
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 clinical communication. 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. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale
Correct answer: D. 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.