Level: Foundational
Difficulty: Easy
Subtopic: Therapeutic diets
NCLEX: A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to therapeutic diets…
Nutrition Basic Care and Comfort
Case Study
A 63-year-old client with chronic kidney disease is being evaluated for nursing care related to therapeutic diets. Assessment data include the client has 6% unintentional weight loss in 1 month and albumin 2.8 g/dL. 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. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
Rationale
Correct answer: C. 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.