Nutrition · practice question

A 58-year-old client after a stroke is being evaluated for nursing care related to hydration and fluid balance. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. Which nursing action is the priority to keep the client safe?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026nutrition

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.Wait for the provider's routine visit before acting on abnormal findings.

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 58-year-old client after a stroke is being evaluated for nursing care related to hydration and fluid balance. Assessment data include the client has heart failure, 2+ edema, and a 2 kg weight gain in 24 hours. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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