Nursing fundamentals · practice question

An 82-year-old client on a medical-surgical unit is being evaluated for postoperative monitoring. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Which nursing action should the nurse take first?

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

Document the client as stable without reassessment.Give a blanket answer that everything is fine and continue the prior plan.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Implement the final step of the care plan before assessing the client.

Answer and explanation

Correct answer

C. 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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An 82-year-old client on a medical-surgical unit is being evaluated for postoperative monitoring. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Which nursing action should the nurse take first?

Correct answer

Why

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