Level: Foundational
Difficulty: Easy
Subtopic: Gastrointestinal disorders
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for partial bowel obstruction. Assessment data in…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for partial bowel obstruction. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. 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. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
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.