Level: Clinical
Difficulty: Medium
Subtopic: Gastrointestinal digestion and absorption
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to gastrointestinal…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to gastrointestinal digestion and absorption. Assessment data include the nurse notes an unexpected finding during routine assessment. 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. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
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. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
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.