Level: Clinical
Difficulty: Medium
Subtopic: Change management
NCLEX: The charge nurse on a medical-surgical unit is being evaluated for nursing care related to change management. Ass…
Leadership and management Management of Care
Case Study
The charge nurse on a medical-surgical unit is being evaluated for nursing care related to change management. Assessment data include UAP reports the client fell in the bathroom. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.