Anatomy & Physiology I/II · practice question

A 62-year-old client on a postoperative unit is being evaluated for nursing care related to renal fluid and electrolyte regulation. Assessment data include the nurse notes an unexpected finding during routine assessment. Which nursing action should the nurse take first?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026anatomy-physiology

Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.

Answer and explanation

Correct answer

A. 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 nursing care related to renal fluid and electrolyte regulation. Assessment data include the nurse notes an unexpected finding during routine assessment. Which nursing action should the nurse take first?

Correct answer

Why

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