Level: Clinical
Difficulty: Medium
Subtopic: Quality improvement
NCLEX: The nurse manager during a busy day shift is being evaluated for nursing care related to quality improvement. Ass…
Leadership and management Management of Care
Case Study
The nurse manager during a busy day shift is being evaluated for nursing care related to quality improvement. Assessment data include new chest pain rated 8/10 with diaphoresis. 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. Complete nonurgent tasks first because the client appears calm.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Complete nonurgent tasks first because the client appears calm.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. 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.