Level: Clinical
Difficulty: Medium
Subtopic: Mandatory reporting
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to mandatory reporting. Asse…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for nursing care related to mandatory reporting. Assessment data include family requests lab results by phone without verified authorization. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that family requests lab results by phone without verified authorization.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that family requests lab results by phone without verified authorization.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that family requests lab results by phone without verified authorization.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.