Level: Clinical
Difficulty: Medium
Subtopic: Dysphagia and aspiration risk
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to dysphagia and aspi…
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to dysphagia and aspiration risk. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale
Correct answer: D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.