Level: Clinical
Difficulty: Medium
Subtopic: Enteral nutrition
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to enteral nutrition….
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 enteral nutrition. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.