Level: Foundational
Difficulty: Easy
Subtopic: Prioritization frameworks
NCLEX: The charge nurse on a medical-surgical unit is being evaluated for nursing care related to prioritization framewo…
Leadership and management Management of Care
Case Study
The charge nurse on a medical-surgical unit is being evaluated for nursing care related to prioritization frameworks. Assessment data include UAP reports the client fell in the bathroom. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that UAP reports the client fell in the bathroom.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that UAP reports the client fell in the bathroom.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that UAP reports the client fell in the bathroom.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.