Level: Foundational
Difficulty: Easy
Subtopic: Cardiac conduction and perfusion
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to cardiac conduction an…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to cardiac conduction and perfusion. Assessment data include the client refuses a recommended intervention and requests another option. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: A. 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.