Level: Foundational
Difficulty: Easy
Subtopic: Clinical decision support
NCLEX: The telehealth nurse during a virtual follow-up visit is being evaluated for technology-supported nursing care an…
Informatics and healthcare technology Management of Care
Case Study
The telehealth nurse during a virtual follow-up visit is being evaluated for technology-supported nursing care and clinical decision support. Assessment data include the barcode scanner displays a medication-client mismatch at the bedside. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.