Level: Foundational
Difficulty: Easy
Subtopic: Gastrointestinal disorders
NCLEX: A 45-year-old client in the emergency department is being evaluated for partial bowel obstruction. Assessment dat…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for partial bowel obstruction. Assessment data include surgical incision with purulent drainage and fever 101.5°F (38.6°C). Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Administer the next scheduled intervention before reassessing the client.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.