Level: Advanced
Difficulty: Hard
Subtopic: Immune and inflammatory response
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to immune and inflammato…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to immune and inflammatory response. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Choosing an intervention before identifying assessment cues and immediate safety risk.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Choosing an intervention before identifying assessment cues and immediate safety risk.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: B. 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.