Level: Foundational
Difficulty: Easy
Subtopic: Fluid volume excess and deficit
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to fluid volume exce…
Pathophysiology Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to fluid volume excess and deficit. Assessment data include surgical incision with purulent drainage and fever 101.5°F (38.6°C). Which action is appropriate within the RN scope of practice?
Question
A. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
B. Independently diagnose the medical disease and prescribe treatment.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
B. Independently diagnose the medical disease and prescribe treatment.
C. Prescribe new medications without a provider order.
D. Delegate nursing assessment and evaluation on an unstable client.
Rationale
Correct answer: A. 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.