Leadership and management · practice question

The charge nurse on a medical-surgical unit is being evaluated for nursing care related to change management. Assessment data include telephone order received for a high-risk IV medication. Which nursing action should the nurse take first?

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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.Document the client as stable without reassessment.Apply restraints without assessing less restrictive safety options first.

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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The charge nurse on a medical-surgical unit is being evaluated for nursing care related to change management. 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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