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 reports no sleep and increasing agitation overnight. Which nursing action is the priority to keep the client safe?

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

Administer the next scheduled intervention before reassessing the client.Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.Leave the client alone to promote independence while finishing charting.Apply the first intervention in the policy manual without a current assessment.

Answer and explanation

Correct answer

B. 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 74-year-old client on a medical-surgical unit is being evaluated for cardiovascular assessment during hospitalization. Assessment data include the client reports no sleep and increasing agitation overnight. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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