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 beneficence and nonmaleficence. Assessment data include provider order for a medication the client is allergic to on the chart. 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.Implement the final step of the care plan before assessing the client.Document the client as stable without reassessment.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 beneficence and nonmaleficence. Assessment data include provider order for a medication the client is allergic to on the chart. Which nursing action should the nurse take first?

Correct answer

Why

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