Level: Clinical
Difficulty: Medium
Subtopic: Parenteral nutrition
NCLEX: A 58-year-old client after a stroke is being evaluated for nursing care related to parenteral nutrition. Assessme…
Nutrition Basic Care and Comfort
Case Study
A 58-year-old client after a stroke is being evaluated for nursing care related to parenteral nutrition. Assessment data include the client has 6% unintentional weight loss in 1 month and albumin 2.8 g/dL. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Complete nonurgent tasks first because the client appears calm.
B. Apply the first intervention in the policy manual without a current assessment.
C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: C. 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.