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 the electronic health record shows two clients with similar names on the same unit. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
Rationale
Correct answer: A. 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.