Level: Clinical
Difficulty: Medium
Subtopic: Abdominal assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for abdominal assessment during hospitalizatio…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for abdominal assessment during hospitalization. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
Rationale
Correct answer: C. 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.