Level: Advanced
Difficulty: Hard
Subtopic: Oxidation and cellular energy
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to oxidation and cellula…
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 oxidation and cellular energy. Assessment data include client appears anxious and asks for help understanding the care plan. 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. Administer the next scheduled intervention before reassessing the client.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
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.