Level: Advanced
Difficulty: Hard
Subtopic: Oxidation and cellular energy
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to oxidation and cellula…
Chemistry or biochemistry basics Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to oxidation and cellular energy. Assessment data include the client develops redness and warmth at an IV insertion site. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Reassessing the client after an appropriate intervention.
C. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
B. Reassessing the client after an appropriate intervention.
C. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: C. 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.