Level: Foundational
Difficulty: Easy
Subtopic: Acids, bases, and pH
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to acids, bases, and…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to acids, bases, and ph. Assessment data include the client develops redness and warmth at an IV insertion site. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: A. 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.