Level: Foundational
Difficulty: Easy
Subtopic: Electrolyte charge and movement
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to electrolyte charg…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to electrolyte charge and movement. 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. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: A. 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.