Level: Clinical
Difficulty: Medium
Subtopic: Scope of practice
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assess…
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 scope of practice. Assessment data include telephone order received for a high-risk IV medication. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: B. 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.