Nursing fundamentals · practice question

An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to elimination. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which nursing action should the nurse take first?

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Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the finding and recheck at the end of the shift without further assessment.Implement the final step of the care plan before assessing the client.Document the client as stable without reassessment.

Answer and explanation

Correct answer

A. 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 nursing care related to elimination. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which nursing action should the nurse take first?

Correct answer

Why

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