Level: Foundational
Difficulty: Easy
Subtopic: Validity and reliability
NCLEX: The quality-improvement nurse reviewing fall-rate data is being evaluated for evidence-based practice and validit…
Statistics or evidence-based practice Management of Care
Case Study
The quality-improvement nurse reviewing fall-rate data is being evaluated for evidence-based practice and validity and reliability. Assessment data include pain scores decreased after an intervention, but sedation events also increased. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: A. 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.