Level: Foundational
Difficulty: Easy
Subtopic: Primary prevention
NCLEX: The community health nurse at a public health clinic is being evaluated for risk related to primary prevention. A…
Community / public health nursing Health Promotion and Maintenance
Case Study
The community health nurse at a public health clinic is being evaluated for risk related to primary prevention. Assessment data include vaccination records show several children are overdue for required immunizations. 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.