Ethics, legal nursing, delegation, prioritization · practice question

A 58-year-old client on a telemetry unit is being evaluated for nursing care related to unsafe orders. Assessment data include family requests lab results by phone without verified authorization. Which nursing action should the nurse take first?

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Give a blanket answer that everything is fine and continue the prior plan.Document the client as stable without reassessment.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Implement the final step of the care plan before assessing the client.

Answer and explanation

Correct answer

C. 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 unsafe orders. Assessment data include family requests lab results by phone without verified authorization. Which nursing action should the nurse take first?

Correct answer

Why

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