# Stage 5 — Take action. The PE-response team has evaluated the client and therapeutic anticoagulation is prescribed. Place the following nursing actions in the best priority sequence. Closely related steps should be initiated without unnecessary delay.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372449&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

Stage 5 — Take action. The PE-response team has evaluated the client and therapeutic anticoagulation is prescribed. Place the following nursing actions in the best priority sequence. Closely related steps should be initiated without unnecessary delay.

Reassess oxygenation, hemodynamics, chest symptoms, and bleeding; prepare for urgent advanced therapy if the client deteriorates

Maintain continuous cardiac and pulse-oximetry monitoring; verify IV access, allergies, CBC, platelet count, renal function, and bleeding-risk findings

Document the response, medication administration, reassessments, team communication, and transfer or handoff plan

Continue prescribed oxygen, position for ease of breathing, and immediately reassess SpO2, respiratory effort, BP, and mental status

Administer the prescribed therapeutic anticoagulant using the agent-specific protocol and an independent safety check when required

## Explanation

Best priority sequence
1) Continue oxygen and perform an immediate ABC-focused reassessment. 2) Maintain continuous monitoring and verify the safety data needed for the ordered anticoagulant. 3) Administer anticoagulation using the agent-specific protocol. 4) Reassess for improvement, deterioration, and bleeding while preparing to escalate if needed. 5) Complete documentation and handoff. The first three steps occur in rapid succession and should not be interpreted as permission to delay monitoring, team communication, or treatment.

## In-depth explanation

Step 1 — Stabilize and reassess
Continue the already prescribed oxygen, position for easier breathing, and reassess oxygenation, breathing effort, BP, and mental status. This confirms the client's current state before medication administration.

Step 2 — Build the treatment safety check
Continuous monitoring, reliable IV access, allergies, CBC, platelet count, renal function, and bleeding risk guide safe anticoagulant administration. This is not a rule that every client needs two large-bore IVs.

Step 3 — Administer and close the loop
Give the prescribed agent using its specific protocol, then reassess both therapeutic response and bleeding. Prepare for urgent escalation if hypotension, worsening hypoxemia, altered mental status, or other deterioration develops. Document without delaying care.

Key concept
An order item represents the best priority sequence; real emergency actions may overlap and should proceed without artificial waiting.

## Clinical scenario

Scenario (Stage 5 — Take action)
The PE-response team has evaluated the client, and therapeutic anticoagulation is now prescribed. Sequence stabilization, medication-safety checks, administration, reassessment, and documentation.

Background
NCJMM Stage 5 — Choose the best priority sequence while recognizing that closely related emergency actions may overlap.

## Key concepts

- **Priority sequencing in acute care** — Address immediate breathing and circulation threats first, then complete medication-safety checks, administer prescribed therapy, and reassess. Closely related steps may be performed concurrently by the care team.
- **Anticoagulant safety check** — Verify the prescribed agent, dose, route, allergies, CBC, platelet count, renal function, bleeding risk, and required independent checks or monitoring before administration.
- **Documentation timing** — Real-time charting is preferred but should not delay urgent care. Complete documentation after immediate priorities are stabilized; ensure family communication is also recorded.

## Related questions

- [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en)
- [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en)
- [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en)
- [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en)
- [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en)
- [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en)
- [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en)
- [A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory resu…](https://mymerci.kr/pages/nclex_q.php?qn_id=366294&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=372449&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=372449&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=372449&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=372449&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=372449&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._