Level: Foundational
Difficulty: Easy
Subtopic: Cardiac conduction and perfusion
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to cardiac conduction…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to cardiac conduction and perfusion. Assessment data include laboratory results return outside the expected range for this condition. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.