Microbiology · practice question

A 71-year-old client in a long-term care facility is being evaluated for nursing care related to vaccination and herd protection. Assessment data include productive cough for 2 weeks with night sweats and hemoptysis. Which nursing action should the nurse take first?

Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026microbiology

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.Administer the next scheduled intervention before reassessing the client.Document the client as stable without reassessment.

Answer and explanation

Correct answer

B. 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 71-year-old client in a long-term care facility is being evaluated for nursing care related to vaccination and herd protection. Assessment data include productive cough for 2 weeks with night sweats and hemoptysis. Which nursing action should the nurse take first?

Correct answer

Why

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