Level: Clinical
Difficulty: Medium
Subtopic: Hypoxia and impaired gas exchange
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to hypoxia and impair…
Pathophysiology Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.