Level: Foundational
Difficulty: Easy
Subtopic: Cardiac medications
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for heart failure and diuretic therapy. Assess…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for heart failure and diuretic therapy. Assessment data include bleeding from the IV site and platelets below the ordered threshold. 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. Give a blanket answer that everything is fine and continue the prior plan.
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. Give a blanket answer that everything is fine and continue the prior plan.
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.