Level: Foundational
Difficulty: Easy
Subtopic: Analyze cues
NCLEX: A client in an unfolding case study is being evaluated for nursing care related to analyze cues. Assessment data…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
A client in an unfolding case study 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 is appropriate within the RN scope of practice?
Question
A. Independently diagnose the medical disease and prescribe treatment.
B. Prescribe new medications without a provider order.
C. Delegate nursing assessment and evaluation on an unstable client.
D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
B. Prescribe new medications without a provider order.
C. Delegate nursing assessment and evaluation on an unstable client.
D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale
Correct answer: D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.