Adult health / medical-surgical nursing · practice question

A 59-year-old client in the intensive care unit is being evaluated for heart failure exacerbation. Assessment data include bilateral calf pain with redness and warmth after bedrest. Which assessment approach should the nurse use first?

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

Screen for instability, then perform a focused assessment related to the presenting concern.Use only the chart from admission without current data.Defer assessment until all medications are administered.Begin invasive procedures before any focused assessment.

Answer and explanation

Correct answer

A. Screen for instability, then perform a focused assessment related to the presenting concern.

Why

Assessment begins with stability screening and focused data collection before invasive or delayed actions.

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A 59-year-old client in the intensive care unit is being evaluated for heart failure exacerbation. Assessment data include bilateral calf pain with redness and warmth after bedrest. Which assessment approach should the nurse use first?

Correct answer

Why

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