Level: Clinical
Difficulty: Medium
Subtopic: Risk and probability
NCLEX: The quality-improvement nurse reviewing fall-rate data is being evaluated for evidence-based practice and risk an…
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 risk and probability. Assessment data include fall rates increased from 2.1 to 4.8 per 1,000 patient days after a process change. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Complete nonurgent tasks first because the client appears calm.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.