Health assessment · practice question

A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which action should the nurse take first?

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

Complete all remaining scheduled tasks before reassessing the client.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.Apply restraints without assessing less restrictive safety options first.

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 skin and wound assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which action should the nurse take first?

Correct answer

Why

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