Adult health / medical-surgical nursing · practice question
A 59-year-old client in the intensive care unit is being evaluated for pneumonia with increased work of breathing. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which assessment approach should the nurse use first?
Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg
Answer and explanation
Correct answer
C. 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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