Level: Advanced
Difficulty: Hard
Subtopic: Translating evidence into practice
NCLEX: The RN evaluating a clinical practice guideline is being evaluated for evidence-based practice and translating ev…
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 translating evidence into practice. Assessment data include pain scores decreased after an intervention, but sedation events also increased. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Give a blanket answer that everything is fine and continue the prior plan.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Give a blanket answer that everything is fine and continue the prior plan.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.