Level: Foundational
Difficulty: Easy
Subtopic: Tertiary prevention
NCLEX: The home health nurse during an initial home visit is being evaluated for risk related to tertiary prevention. As…
Community / public health nursing Health Promotion and Maintenance
Case Study
The home health nurse during an initial home visit is being evaluated for risk related to tertiary prevention. Assessment data include vaccination records show several children are overdue for required immunizations. 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. Complete nonurgent tasks first because the client appears calm.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Complete nonurgent tasks first because the client appears calm.
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.