Level: Advanced
Difficulty: Hard
Subtopic: Laboratory reference reasoning
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to laboratory refere…
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 laboratory reference reasoning. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. 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. Document the finding and recheck at the end of the shift without further assessment.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Document the finding and recheck at the end of the shift without further assessment.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. 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.