Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for high fall risk on a medical unit. Assessm…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
An 82-year-old client on a medical-surgical unit is being evaluated for high fall risk on a medical unit. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Which action is appropriate within the RN scope of practice?
Question
A. Independently diagnose the medical disease and prescribe treatment.
B. Prescribe new medications without a provider order.
C. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
D. Delegate nursing assessment and evaluation on an unstable client.
B. Prescribe new medications without a provider order.
C. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
D. Delegate nursing assessment and evaluation on an unstable client.
Rationale
Correct answer: C. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.