Nursing fundamentals · practice question

A 70-year-old client in a rehabilitation facility is being evaluated for new admission assessment. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Which nursing action is the priority to keep the client safe?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals

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.Tell the client symptoms are expected and avoid notifying the health care team.

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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A 70-year-old client in a rehabilitation facility is being evaluated for new admission assessment. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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