Level: Advanced
Difficulty: Hard
Subtopic: Pain basics
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to pain basics. 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 pain basics. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. 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. Administer the next scheduled intervention before reassessing 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. Administer the next scheduled intervention before reassessing the client.
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.