Level: Foundational
Difficulty: Easy
Subtopic: Cardiac disorders
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for heart failure exacerbation. Assessment data i…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for heart failure exacerbation. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale
Correct answer: D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.