Adult health / medical-surgical nursing · practice question

A 45-year-old client in the emergency department is being evaluated for pancytopenia after chemotherapy. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which nursing action is the priority to keep the client safe?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg

Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.Apply the first intervention in the policy manual without a current assessment.Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.Leave the client alone to promote independence while finishing charting.

Answer and explanation

Correct answer

C. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Why

Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.

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A 45-year-old client in the emergency department is being evaluated for pancytopenia after chemotherapy. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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