Level: Clinical
Difficulty: Medium
Subtopic: Elimination
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to elimination. Asse…
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 nursing care related to elimination. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: A. 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.