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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 autonomy and informed consent. Assessment data include telephone order received for a high-risk IV medication. Which assessment approach should the nurse use first?

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Choose one answer
Answer and explanation

Correct answer

C. Screen for instability, then perform a focused assessment related to the presenting concern.

Why

Assessment begins with stability screening and focused data collection before invasive or delayed actions.

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