Nutrition · practice question

A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to enteral nutrition. 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 choiceMediumnclex-rn-bsnnclex-validatednclex-2026nutrition

Apply the first intervention in the policy manual without a current assessment.Give a blanket answer that everything is fine and continue the prior plan.Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.Leave the client alone to promote independence while finishing charting.

Answer and explanation

Correct answer

C. 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 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to enteral nutrition. 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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