Community / public health nursing · practice question

The school nurse during a vaccination clinic is being evaluated for risk related to primary prevention. Assessment data include a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg. Which nursing action is the priority to keep the client safe?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026community-public-health

Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.Apply the first intervention in the policy manual without a current assessment.Tell the client symptoms are expected and avoid notifying the health care team.Leave the client alone to promote independence while finishing charting.

Answer and explanation

Correct answer

A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Why

Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.

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The school nurse during a vaccination clinic is being evaluated for risk related to primary prevention. Assessment data include a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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