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 the client has not voided in 8 hours and lower abdomen is firm and tender. Before teaching, what should the nurse assess first?

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

Begin a long lecture while the client is in acute distress.Assume understanding without checking literacy or readiness.Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.Delegate all teaching without RN evaluation of learning needs.

Answer and explanation

Correct answer

C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.

Why

Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.

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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 the client has not voided in 8 hours and lower abdomen is firm and tender. Before teaching, what should the nurse assess first?

Correct answer

Why

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