NCLEX: A senior nursing student during a supervised medication pass is being evaluated for transition-to-practice skills…

Professional nursing practice (clinical transition) Management of Care

Case Study

A senior nursing student during a supervised medication pass is being evaluated for transition-to-practice skills and professional behavior. Assessment data include the student receives feedback about incomplete SBAR during handoff. Which nursing action is the priority to keep the client safe?

Question

A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Apply restraints without assessing less restrictive safety options first.

Rationale

Correct answer: A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.

Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.

Level: Advanced

Difficulty: Hard

Subtopic: Professional behavior