Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalizat…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Apply restraints without assessing less restrictive safety options first.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Apply restraints without assessing less restrictive safety options first.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.