Health assessment · practice question

A 49-year-old client in the emergency department is being evaluated for abdominal assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which nursing action should the nurse take first?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026health-assessment

Tell the client symptoms are expected and avoid notifying the health care team.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.Document the client as stable without reassessment.

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 49-year-old client in the emergency department is being evaluated for abdominal assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which nursing action should the nurse take first?

Correct answer

Why

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