Level: Foundational
Difficulty: Easy
Subtopic: Analyze cues
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to analyze cues. Ass…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for nursing care related to analyze cues. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Wait for the provider's routine visit before acting on abnormal findings.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Wait for the provider's routine visit before acting on abnormal findings.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.