Level: Foundational
Difficulty: Easy
Subtopic: Beneficence and nonmaleficence
NCLEX: A 39-year-old client in the emergency department is being evaluated for nursing care related to beneficence and n…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 39-year-old client in the emergency department is being evaluated for nursing care related to beneficence and nonmaleficence. Assessment data include new chest pain rated 8/10 with diaphoresis. 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. Wait for the provider's routine visit before acting on abnormal findings.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Wait for the provider's routine visit before acting on abnormal findings.
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.