Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal assessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for musculoskeletal assessment during hospitaliza…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for musculoskeletal assessment during hospitalization. Assessment data include pain 9/10 and guards the abdomen after surgery. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.