Level: Advanced
Difficulty: Hard
Subtopic: Renal impairment
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to renal impairment. Ass…
Pathophysiology Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to renal impairment. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. 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.