Level: Advanced
Difficulty: Hard
Subtopic: Focused reassessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for focused reassessment during hospitalization….
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for focused reassessment during hospitalization. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. 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. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: C. 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.