Level: Advanced
Difficulty: Hard
Subtopic: Oxidation and cellular energy
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to oxidation and cel…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to oxidation and cellular energy. Assessment data include the client reports a new symptom that differs from the baseline assessment. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.