Level: Foundational
Difficulty: Easy
Subtopic: Respiratory disorders
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for pneumonia with increased work of breathing. A…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for pneumonia with increased work of breathing. Assessment data include urine output 15 mL/hr for 2 hours with rising creatinine. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.