Level: Advanced
Difficulty: Hard
Subtopic: Emergency deterioration
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for rapidly worsening vital signs. Assessment dat…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for rapidly worsening vital signs. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Before teaching, what should the nurse assess first?
Question
A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.