Ethics, legal nursing, delegation, prioritization · practice question
A 64-year-old client on a medical-surgical unit is being evaluated for a busy medical-surgical assignment. Assessment data include new chest pain rated 8/10 with diaphoresis. Which nursing action should the nurse take first?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026ethics-legal-delegation-prioritization
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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