Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for high fall risk on a medical unit. Assessm…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
An 82-year-old client on a medical-surgical unit is being evaluated for high fall risk on a medical unit. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. 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. Apply restraints without assessing less restrictive safety options first.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Apply restraints without assessing less restrictive safety options first.
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.