Ethics, legal nursing, delegation, prioritization · practice question
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to unsafe orders. Assessment data include new chest pain rated 8/10 with diaphoresis. Which assessment approach should the nurse use first?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026ethics-legal-delegation-prioritization
Answer and explanation
Correct answer
B. Screen for instability, then perform a focused assessment related to the presenting concern.
Why
Assessment begins with stability screening and focused data collection before invasive or delayed actions.
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