Level: Clinical
Difficulty: Medium
Subtopic: Patient portals
NCLEX: The RN using the electronic health record is being evaluated for technology-supported nursing care and patient po…
Informatics and healthcare technology Management of Care
Case Study
The RN using the electronic health record is being evaluated for technology-supported nursing care and patient portals. 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. Apply restraints without assessing less restrictive safety options first.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Apply restraints without assessing less restrictive safety options first.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. 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.