Level: Foundational
Difficulty: Easy
Subtopic: Recognize cues
NCLEX: The nurse reviewing updated assessment data is being evaluated for unfolding changes in a case study. The nurse r…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
The nurse reviewing updated assessment data is being evaluated for unfolding changes in a case study. The nurse reviews this trend: potassium trending from 4.0 to 5.6 mEq/L with muscle weakness. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.