Level: Clinical
Difficulty: Medium
Subtopic: Clinical practice guidelines
NCLEX: The nurse reviewing a unit quality dashboard is being evaluated for evidence-based practice and clinical practice…
Statistics or evidence-based practice Management of Care
Case Study
The nurse reviewing a unit quality dashboard is being evaluated for evidence-based practice and clinical practice guidelines. Assessment data include pain scores decreased after an intervention, but sedation events also increased. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Apply restraints without assessing less restrictive safety options first.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: A. 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.