Level: Foundational
Difficulty: Easy
Subtopic: Respiratory disorders
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for pneumonia with increased work of breathing. A…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for pneumonia with increased work of breathing. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which error is most dangerous on the NCLEX and in practice?
Question
A. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: A. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.