Level: Foundational
Difficulty: Easy
Subtopic: Delegation to assistive personnel
NCLEX: The nurse manager during a busy day shift is being evaluated for nursing care related to delegation to assistive…
Leadership and management Management of Care
Case Study
The nurse manager during a busy day shift is being evaluated for nursing care related to delegation to assistive personnel. Assessment data include UAP reports the client fell in the bathroom. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: B. 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.