Level: Foundational
Difficulty: Easy
Subtopic: Therapeutic diets
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to therapeutic diets….
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit 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 error is most dangerous on the NCLEX and in practice?
Question
A. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: A. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.