Physiological Adaptation Practice Question

Question

The nurse is caring for a client after a stroke and is focused on postoperative deterioration scenario 9. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Delegate the clinical assessment and nursing judgment to assistive personnel.
3. C. Assess airway, circulation, pain, incision, and early complications.
4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

C. Assess airway, circulation, pain, incision, and early complications.

Explanation

The priority action for postoperative deterioration is to assess airway, circulation, pain, incision, and early complications. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: medium
• Domain: Physiological Adaptation
• Objective: postoperative deterioration

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