Pathophysiology · practice question

A 59-year-old client in the intensive care unit is being evaluated for clotting and bleeding disorder. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which assessment approach should the nurse use first?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026pathophysiology

Begin invasive procedures before any focused assessment.Use only the chart from admission without current data.Defer assessment until all medications are administered.Screen for instability, then perform a focused assessment related to the presenting concern.

Answer and explanation

Correct answer

D. Screen for instability, then perform a focused assessment related to the presenting concern.

Why

Assessment begins with stability screening and focused data collection before invasive or delayed actions.

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A 59-year-old client in the intensive care unit is being evaluated for clotting and bleeding disorder. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which assessment approach should the nurse use first?

Correct answer

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