Level: Foundational
Difficulty: Easy
Subtopic: Cardiovascular assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for cardiovascular assessment during hospitali…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for cardiovascular assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. 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. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
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.