Nursing fundamentals · practice question

A 76-year-old client in a long-term care facility is being evaluated for nursing care related to documentation fundamentals. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Before teaching, what should the nurse assess first?

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

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

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 76-year-old client in a long-term care facility is being evaluated for nursing care related to documentation fundamentals. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Before teaching, what should the nurse assess first?

Correct answer

Why

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