Level: Advanced
Difficulty: Hard
Subtopic: Immune and inflammatory response
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to immune and inflammato…
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 immune and inflammatory response. Assessment data include the client refuses a recommended intervention and requests another option. 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. Administer the next scheduled intervention before reassessing the client.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Administer the next scheduled intervention before reassessing the client.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.