Level: Clinical
Difficulty: Medium
Subtopic: Hypoxia and impaired gas exchange
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to hypoxia and impaired…
Pathophysiology Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include surgical incision with purulent drainage and fever 101.5°F (38.6°C). Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Tell the client symptoms are expected and avoid notifying the health care team.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Tell the client symptoms are expected and avoid notifying the health care team.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.