Stage 5 — Take action. The response team arrives as the disoriented client starts climbing over the side rail after pulling off the monitoring leads. Arrange the primary nurse’s immediate bedside loop from first to last while assigned team tasks proceed in parallel.
Ordered Response
Choose your responses, then check the answer.
Explanation
Primary-nurse loop With the team present: establish observation and monitoring → assess ABCs, glucose, and IV access → give protocol-guided benzodiazepine → deliver supportive therapy during parallel evaluation → reassess and escalate. This sequence describes one nurse’s closed loop, not a delay of concurrent team tasks.
Step 1 — Secure the care environment The agitated, disoriented client needs continuous observation and a monitored level of care before the primary nurse turns to individual tasks.
Step 2 — Assess before titration Rapidly establish airway and respiratory status, circulation, glucose, oxygenation, agitation or sedation level, and usable IV access. These findings guide safe IV treatment.
Step 3 — Treat and support in parallel Administer prescribed IV benzodiazepine toward light somnolence and watch ventilation. Thiamine, indicated electrolyte or fluid replacement, diagnostic work, and environmental care can proceed with assigned teammates rather than waiting serially.
Step 4 — Close the loop Reassess with an objective scale plus respiratory, hemodynamic, cognitive, and safety findings. Escalate if agitation is refractory, sedation is excessive, or the trajectory suggests another cause.
NCLEX rule In a team emergency, sequence the primary nurse’s closed loop while recognizing that other roles occur concurrently.
Scenario (Stage 5 — Take action)The response team has arrived. Sequence the primary nurse’s immediate bedside loop while other clinicians work in parallel.
Clinical judgment targetUse monitoring–assessment–treatment–reassessment without artificial whole-team delays.
Closed-loop reassessment — A cycle that measures response after treatment and triggers escalation for inadequate control or adverse effects.
Refractory withdrawal — Withdrawal signs that remain inadequately controlled despite appropriate first-line treatment and require higher-level management.
Concurrent care — Role-based tasks performed in parallel so monitoring, treatment, supportive care, and diagnostic evaluation do not wait on one another.