Level: Clinical
Difficulty: Medium
Subtopic: Enzymes and metabolic pathways
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to enzymes and metabolic…
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 enzymes and metabolic pathways. Assessment data include laboratory results return outside the expected range for this condition. 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. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: C. 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.