Level: Clinical
Difficulty: Medium
Subtopic: Incident reporting
NCLEX: The RN on a telemetry unit is being evaluated for nursing care related to incident reporting. Assessment data inc…
Leadership and management Management of Care
Case Study
The RN on a telemetry unit is being evaluated for nursing care related to incident reporting. 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. Document the finding and recheck at the end of the shift without further assessment.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Document the finding and recheck at the end of the shift without further assessment.
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.