Health assessment · practice question

A 74-year-old client on a medical-surgical unit is being evaluated for skin and wound assessment during hospitalization. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Which nursing action should the nurse take first?

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

Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the finding and recheck at the end of the shift without further assessment.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.

Answer and explanation

Correct answer

A. 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 skin and wound assessment during hospitalization. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Which nursing action should the nurse take first?

Correct answer

Why

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