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 potassium 5.9 mEq/L while asking about salt substitutes. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: A. 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.