Ethics, legal nursing, delegation, prioritization · practice question

A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assessment data include telephone order received for a high-risk IV medication. Which nursing action should the nurse take first?

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Document the finding and recheck at the end of the shift without further assessment.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.

Answer and explanation

Correct answer

B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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A 58-year-old client on a telemetry unit is being evaluated for nursing care related to scope of practice. Assessment data include telephone order received for a high-risk IV medication. Which nursing action should the nurse take first?

Correct answer

Why

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