Level: Advanced
Difficulty: Hard
Subtopic: Vaccination and herd protection
NCLEX: A 71-year-old client in a long-term care facility is being evaluated for nursing care related to vaccination and…
Microbiology Safety and Infection Prevention and Control
Case Study
A 71-year-old client in a long-term care facility is being evaluated for nursing care related to vaccination and herd protection. Assessment data include productive cough for 2 weeks with night sweats and hemoptysis. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: B. 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.