Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for skin and wound 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 skin and wound assessment during hospitalization. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. 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. Document the finding and recheck at the end of the shift without further assessment.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Document the finding and recheck at the end of the shift without further assessment.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.