Level: Clinical
Difficulty: Medium
Subtopic: Clotting and bleeding disorders
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for clotting and bleeding disorder. Assessment da…
Pathophysiology Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for clotting and bleeding disorder. Assessment data include urine output 15 mL/hr for 2 hours with rising creatinine. 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. Document the finding and recheck at the end of the shift without further assessment.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Document the finding and recheck at the end of the shift without further assessment.
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.