Professional nursing practice (clinical transition) · practice question

The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and sbar handoff. Assessment data include simulation data show worsening respiratory distress after the first intervention. Which nursing action should the nurse take first?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026clinical-rotations-skills-simulation-cap

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.Tell the client symptoms are expected and avoid notifying the health care team.

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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The student nurse during simulation debriefing is being evaluated for transition-to-practice skills and sbar handoff. Assessment data include simulation data show worsening respiratory distress after the first intervention. Which nursing action should the nurse take first?

Correct answer

Why

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