Level: Foundational
Difficulty: Easy
Subtopic: Tertiary prevention
NCLEX: The school nurse during a vaccination clinic is being evaluated for risk related to tertiary prevention. Assessme…
Community / public health nursing Health Promotion and Maintenance
Case Study
The school nurse during a vaccination clinic is being evaluated for risk related to tertiary prevention. Assessment data include a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg. 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. Administer the next scheduled intervention before reassessing the client.
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. Administer the next scheduled intervention before reassessing the client.
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.