Level: Clinical
Difficulty: Medium
Subtopic: Protein structure and albumin
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to protein structure and…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to protein structure and albumin. Assessment data include client appears anxious and asks for help understanding the care plan. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: B. 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.