Level: Clinical
Difficulty: Medium
Subtopic: Gastrointestinal digestion and absorption
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to gastrointestinal d…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to gastrointestinal digestion and absorption. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Apply restraints without assessing less restrictive safety options first.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.