Level: Clinical
Difficulty: Medium
Subtopic: Incident reporting
NCLEX: The charge nurse on a medical-surgical unit is being evaluated for nursing care related to incident reporting. As…
Leadership and management Management of Care
Case Study
The charge nurse on a medical-surgical unit is being evaluated for nursing care related to incident reporting. 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. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Apply restraints without assessing less restrictive safety options first.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: C. 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.