Nursing fundamentals · practice question
A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to documentation fundamentals. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which nursing action is the priority to keep the client safe?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals
Answer and explanation
Correct answer
A. 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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