Level: Foundational
Difficulty: Easy
Subtopic: Assignment to LPN or RN
NCLEX: The nurse manager during a busy day shift is being evaluated for nursing care related to assignment to lpn or rn….
Leadership and management Management of Care
Case Study
The nurse manager during a busy day shift is being evaluated for nursing care related to assignment to lpn or rn. Assessment data include family requests lab results by phone without verified authorization. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Complete nonurgent tasks first because the client appears calm.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: C. 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.