Level: Foundational
Difficulty: Easy
Subtopic: Telehealth nursing
NCLEX: A bedside nurse using barcode medication administration is being evaluated for technology-supported nursing care…
Informatics and healthcare technology Management of Care
Case Study
A bedside nurse using barcode medication administration is being evaluated for technology-supported nursing care and telehealth nursing. Assessment data include alarm fatigue is reported after repeated nonactionable monitor alarms overnight. 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. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Administer the next scheduled intervention before reassessing the client.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: C. 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.