# Review the nurse's escalating safety concern and determine the strongest advocacy response.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=563775&lang=en  
> language: en  
> subject: Advocacy  
> category: MOC

## Question

Review the nurse's escalating safety concern and determine the strongest advocacy response.

| Time | Data |
| --- | --- |
| 1400 | BP 108/68 mm Hg, HR 96/min; dressing dry; client awake and reports increasing deep abdominal pressure. |
| 1430 | BP 92/56 mm Hg, HR 116/min; abdomen more distended and skin cool. Nurse reports concern for bleeding; the response is to recheck later. |
| 1445 | BP 78/42 mm Hg, HR 132/min; client is difficult to arouse and urine output is falling. No clinician has assessed the client at bedside. |

Q1. How should the nurse interpret the current situation?

Expected anesthesia recovery
A communication issue that can wait until rounds
Stable pain with no physiologic consequence
Unresolved deterioration with probable internal bleeding and shock

Q2. What is the priority advocacy action?

Document the earlier call and wait
Avoid further contact because the concern was already reported
Activate rapid response, restate the safety threat, and escalate through the chain of command
Ask the family to locate the surgeon

Q3. Which communication best closes the loop?

State the serial findings and requested action, ask the receiver to confirm, and verify the plan and timing
Leave a nonspecific message that the client does not look right
Send a text and assume it was read
Wait for the receiver to review the chart independently

## Explanation

The trend shows ongoing deterioration, not a resolved disagreement. A falling blood pressure, rising pulse, increasing abdominal distention, cool skin, and decreasing responsiveness suggest concealed bleeding and shock. The nurse should state the concern and anticipated danger clearly, request immediate bedside evaluation, and verify that the message is understood. If the response does not alleviate the safety threat, the nurse must activate rapid response and escalate through the chain of command while continuing stabilization. Documentation alone or passive waiting does not fulfill the advocacy duty.

## In-depth explanation

Correct Answer
The nurse must escalate unresolved concern until the client receives timely evaluation and stabilization.

Why It Fits
Serial findings worsen after the initial notification, and the client now has signs of shock and altered responsiveness.

Clinical Picture
Advocacy includes assertive communication, a stronger course of action when a concern is not resolved, and use of the chain of command.

Memory Link
If the danger continues, the escalation continues.

NCLEX Rule
State the risk, request action, confirm receipt, and use rapid response and the chain of command when the threat remains unresolved.

Why the Alternatives Fail
Waiting for rounds, merely charting the call, or avoiding escalation because of hierarchy leaves the client exposed to preventable harm.

Sources
1AHRQ TeamSTEPPS Mutual Support: Advocacy and Assertion
2AHRQ TeamSTEPPS Check-Back Tool
3NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Postoperative unit
A client returned from abdominal surgery two hours ago. The nurse compares serial findings, communicates a specific concern, and evaluates whether the team's response resolves the immediate threat.

## Key concepts

- **Chain of command** — The organizational escalation pathway used when an unresolved concern threatens safe care.
- **CUS** — An assertive communication tool: I am Concerned, I am Uncomfortable, and this is a Safety issue.
- **Check-back** — Closed-loop verification that a message was received and understood correctly.

## Related questions

- [A client with limited English proficiency is preparing to sign consent for a high-risk pro…](https://mymerci.kr/pages/nclex_q.php?qn_id=525980&lang=en)
- [A 70-year-old client is in the preoperative holding area for a scheduled knee arthroplasty…](https://mymerci.kr/pages/nclex_q.php?qn_id=617413&lang=en)
- [An RN is assigning routine care for stable clients on a medical-surgical unit. For each gr…](https://mymerci.kr/pages/nclex_q.php?qn_id=620065&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=563775&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=563775&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=563775&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=563775&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=563775&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._