Level: Foundational
Difficulty: Easy
Subtopic: Assignment to LPN or RN
NCLEX: The RN on a telemetry unit is being evaluated for nursing care related to assignment to lpn or rn. Assessment dat…
Leadership and management Management of Care
Case Study
The RN on a telemetry unit is being evaluated for nursing care related to assignment to lpn or rn. Assessment data include new chest pain rated 8/10 with diaphoresis. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.