Level: Advanced
Difficulty: Hard
Subtopic: Emergency deterioration
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for rapidly worsening vital signs. Assessment…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for rapidly worsening vital signs. Assessment data include urine output 15 mL/hr for 2 hours with rising creatinine. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.