Level: Advanced
Difficulty: Hard
Subtopic: Professional behavior
NCLEX: The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and professio…
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 professional behavior. Assessment data include simulation data show worsening respiratory distress after the first intervention. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.