Pathophysiology · practice question

A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which action should the nurse take first?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026pathophysiology

Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.Complete all remaining scheduled tasks before reassessing the client.Offer a warm blanket and reschedule assessment until after lunch.Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Answer and explanation

Correct answer

D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Why

NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.

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A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include the client reports sudden sharp chest pain and respirations 32/min after surgery. Which action should the nurse take first?

Correct answer

Why

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