Level: Foundational
Difficulty: Easy
Subtopic: Hygiene and comfort
NCLEX: A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to hygiene and comf…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to hygiene and comfort. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. 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. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
B. Reassessing the client after an appropriate intervention.
C. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: C. 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.