Level: Clinical
Difficulty: Medium
Subtopic: SBAR handoff
NCLEX: The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and sbar hand…
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 sbar handoff. Assessment data include simulation data show worsening respiratory distress after the first intervention. 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. Tell the client symptoms are expected and avoid notifying the health care team.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
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.