Adult health / medical-surgical nursing · practice question

A 45-year-old client in the emergency department is being evaluated for rapidly worsening vital signs. Assessment data include hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg. Which nursing action is the priority to keep the client safe?

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

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.Document the finding and recheck at the end of the shift without further assessment.Leave the client alone to promote independence while finishing charting.

Answer and explanation

Correct answer

B. 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 rapidly worsening vital signs. Assessment data include hemoglobin 6.8 g/dL with pallor and hypotension 90/55 mm Hg. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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