Pathophysiology · practice question

A 59-year-old client in the intensive care unit is being evaluated for nursing care related to fluid volume excess and deficit. 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 choiceEasynclex-rn-bsnnclex-validatednclex-2026pathophysiology

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

Answer and explanation

Correct answer

A. 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 nursing care related to fluid volume excess and deficit. 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

Why

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