Level: Advanced
Difficulty: Hard
Subtopic: Unsafe orders
NCLEX: A 39-year-old client in the emergency department is being evaluated for nursing care related to unsafe orders. As…
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 unsafe orders. Assessment data include new chest pain rated 8/10 with diaphoresis. The nurse is evaluating discharge teaching. Which client statement shows correct understanding?
Question
A. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
B. "I will stop my medications when I feel better."
C. "I do not need to report mild symptoms unless they become unbearable."
D. "The nurse does not need to know about changes unless the provider asks."
B. "I will stop my medications when I feel better."
C. "I do not need to report mild symptoms unless they become unbearable."
D. "The nurse does not need to know about changes unless the provider asks."
Rationale
Correct answer: A. "I will call the nurse if I have new or worse symptoms before my follow-up appointment."
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Effective teaching includes when to seek help for worsening symptoms. Stopping medications or delaying reports are unsafe.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.