Level: Foundational
Difficulty: Easy
Subtopic: Justice and fairness
NCLEX: A 39-year-old client in the emergency department is being evaluated for nursing care related to justice and fairn…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 39-year-old client in the emergency department is being evaluated for nursing care related to justice and fairness. Assessment data include telephone order received for a high-risk IV medication. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Wait for the provider's routine visit before acting on abnormal findings.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Wait for the provider's routine visit before acting on abnormal findings.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. 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.
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.