Adult health / medical-surgical nursing · practice question

A 62-year-old client on a postoperative unit is being evaluated for uncontrolled hyperglycemia. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which nursing action should the nurse take first?

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

Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Tell the client symptoms are expected and avoid notifying the health care team.

Answer and explanation

Correct answer

C. 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 uncontrolled hyperglycemia. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which nursing action should the nurse take first?

Correct answer

Why

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