Reduction of Risk Potential Practice Question

Question

The nurse is caring for a client on anticoagulants and is focused on complication monitoring 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. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
4. D. Compare expected findings with warning signs for the diagnosis.

Correct Answer

D. Compare expected findings with warning signs for the diagnosis.

Explanation

The priority action for complication monitoring is to compare expected findings with warning signs for the diagnosis. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: hard
• Domain: Reduction of Risk Potential
• Objective: complication monitoring

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