Pathophysiology · practice question

A 45-year-old client in the emergency department is being evaluated for nursing care related to inflammation and cellular injury. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which nursing action is the priority to keep the client safe?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pathophysiology

Apply the first intervention in the policy manual without a current assessment.Tell the client symptoms are expected and avoid notifying the health care team.Leave the client alone to promote independence while finishing charting.Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Answer and explanation

Correct answer

D. 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 45-year-old client in the emergency department is being evaluated for nursing care related to inflammation and cellular injury. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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