Level: Foundational
Difficulty: Easy
Subtopic: Vital signs
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for postoperative monitoring. Assessment data…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
An 82-year-old client on a medical-surgical unit is being evaluated for postoperative monitoring. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Give a blanket answer that everything is fine and continue the prior plan.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Give a blanket answer that everything is fine and continue the prior plan.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.