Level: Foundational
Difficulty: Easy
Subtopic: Fluid volume excess and deficit
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to fluid volume exces…
Pathophysiology Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to fluid volume excess and deficit. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. 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.