Health assessment · practice question

A 66-year-old client in an outpatient clinic is being evaluated for pain assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which nursing action is the priority to keep the client safe?

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

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.Leave the client alone to promote independence while finishing charting.Document the finding and recheck at the end of the shift without further assessment.

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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A 66-year-old client in an outpatient clinic is being evaluated for pain assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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