Level: Clinical
Difficulty: Medium
Subtopic: Acid-base imbalance
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to acid-base imbalan…
Pathophysiology Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to acid-base imbalance. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Which nursing action is the priority to keep the client safe?
Question
A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
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. Leave the client alone to promote independence while finishing charting.
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: A. 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.