Health assessment · practice question

A 74-year-old client on a medical-surgical unit is being evaluated for cardiovascular assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nursing action should the nurse take first?

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

Document the client as stable without reassessment.Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.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.

Answer and explanation

Correct answer

D. 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 74-year-old client on a medical-surgical unit is being evaluated for cardiovascular assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nursing action should the nurse take first?

Correct answer

Why

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