Level: Foundational
Difficulty: Easy
Subtopic: Cardiac medications
NCLEX: A 45-year-old client in the emergency department is being evaluated for heart failure and diuretic therapy. Asses…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 45-year-old client in the emergency department is being evaluated for heart failure and diuretic therapy. Assessment data include the client reports dizziness, blood pressure 92/58 mm Hg, and heart rate 118/min after the morning dose. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Administer the next scheduled intervention before reassessing the client.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: B. 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.