Level: Clinical
Difficulty: Medium
Subtopic: Clinical practice guidelines
NCLEX: The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and clinical pract…
Statistics or evidence-based practice Management of Care
Case Study
The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and clinical practice guidelines. Assessment data include a small study reports benefit but has no randomization and a high dropout rate. 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. Document the finding and recheck at the end of the shift without further assessment.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Document the finding and recheck at the end of the shift without further assessment.
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.