Level: Foundational
Difficulty: Easy
Subtopic: Epidemiology basics
NCLEX: The school nurse during a vaccination clinic is being evaluated for community health nursing and epidemiology bas…
Community / public health nursing Health Promotion and Maintenance
Case Study
The school nurse during a vaccination clinic is being evaluated for community health nursing and epidemiology basics. 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. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.