Level: Advanced
Difficulty: Hard
Subtopic: Sleep and rest
NCLEX: An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to sleep and rest. A…
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 sleep and rest. Assessment data include pain 9/10 and guards the abdomen after surgery. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.