Health assessment · practice question

A 66-year-old client in an outpatient clinic is being evaluated for cardiovascular assessment during hospitalization. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Which action should the nurse take first?

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

Give a blanket answer that everything is fine and continue the prior plan.Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.Offer a warm blanket and reschedule assessment until after lunch.Complete all remaining scheduled tasks before reassessing the client.

Answer and explanation

Correct answer

B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Why

NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.

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A 66-year-old client in an outpatient clinic is being evaluated for cardiovascular assessment during hospitalization. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Which action should the nurse take first?

Correct answer

Why

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