Level: Advanced
Difficulty: Hard
Subtopic: Professional behavior
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 preceptor stops a medication pass because the student did not verify two identifiers. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: C. 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.