Level: Foundational
Difficulty: Easy
Subtopic: Beneficence and nonmaleficence
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to beneficence and no…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to beneficence and nonmaleficence. Assessment data include provider order for a medication the client is allergic to on the chart. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.