Level: Foundational
Difficulty: Easy
Subtopic: Hygiene and comfort
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to hygiene and comfo…
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 nursing care related to hygiene and comfort. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. 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. Complete nonurgent tasks first because the client appears calm.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
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.