Pathophysiology · practice question

A 62-year-old client on a postoperative unit is being evaluated for nursing care related to shock states. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Which nursing action should the nurse take first?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pathophysiology

Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.Give a blanket answer that everything is fine and continue the prior plan.

Answer and explanation

Correct answer

A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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A 62-year-old client on a postoperative unit is being evaluated for nursing care related to shock states. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Which nursing action should the nurse take first?

Correct answer

Why

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