Adult health / medical-surgical nursing · practice question

A 62-year-old client on a postoperative unit is being evaluated for pancytopenia after chemotherapy. Assessment data include urine output 15 mL/hr for 2 hours with rising creatinine. Which nursing action should the nurse take first?

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

Implement the final step of the care plan before assessing the client.Document the client as stable without reassessment.Document the finding and recheck at the end of the shift without further assessment.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Answer and explanation

Correct answer

D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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A 62-year-old client on a postoperative unit is being evaluated for pancytopenia after chemotherapy. Assessment data include urine output 15 mL/hr for 2 hours with rising creatinine. Which nursing action should the nurse take first?

Correct answer

Why

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