Ethics, legal nursing, delegation, prioritization · practice question

A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to advance directives. Assessment data include family requests lab results by phone without verified authorization. Which nursing action should the nurse take first?

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Document the client as stable without reassessment.Apply restraints without assessing less restrictive safety options first.Implement the final step of the care plan before assessing the client.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Answer and explanation

Correct answer

D. 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 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to advance directives. 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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