Pathophysiology · practice question

A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to shock states. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which action should the nurse take first?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pathophysiology

Offer a warm blanket and reschedule assessment until after lunch.Complete all remaining scheduled tasks before reassessing the client.Wait for the provider's routine visit before acting on abnormal findings.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 shock states. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which action should the nurse take first?

Correct answer

Why

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