Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for skin and wound assessment during hospitali…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for skin and wound assessment during hospitalization. Assessment data include pain 9/10 and guards the abdomen after surgery. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
Rationale
Correct answer: B. 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.