Level: Advanced
Difficulty: Hard
Subtopic: Resource management
NCLEX: The RN on a telemetry unit is being evaluated for nursing care related to resource management. Assessment data in…
Leadership and management Management of Care
Case Study
The RN on a telemetry unit is being evaluated for nursing care related to resource management. 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. Document the finding and recheck at the end of the shift without further assessment.
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. Document the finding and recheck at the end of the shift without further assessment.
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.