Nursing fundamentals · practice question

An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to mobility and positioning. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which action should the nurse take first?

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

Give a blanket answer that everything is fine and continue the prior plan.Complete all remaining scheduled tasks before reassessing the client.Offer a warm blanket and reschedule assessment until after lunch.Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Answer and explanation

Correct answer

D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Why

NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.

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An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to mobility and positioning. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which action should the nurse take first?

Correct answer

Why

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