Level: Clinical
Difficulty: Medium
Subtopic: Enteral nutrition
NCLEX: A 58-year-old client after a stroke is being evaluated for nursing care related to enteral nutrition. Assessment…
Nutrition Basic Care and Comfort
Case Study
A 58-year-old client after a stroke is being evaluated for nursing care related to enteral nutrition. Assessment data include the client has potassium 5.9 mEq/L while asking about salt substitutes. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale
Correct answer: D. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.