Reduction of Risk Potential Practice Question

Question

The nurse is caring for a client at risk for aspiration and is focused on changes in condition scenario 1. 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. Recognize early deterioration and escalate care promptly.
4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

C. Recognize early deterioration and escalate care promptly.

Explanation

The priority action for changes in condition is to recognize early deterioration and escalate care promptly. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: medium
• Domain: Reduction of Risk Potential
• Objective: changes in condition

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