Level: Foundational
Difficulty: Easy
Subtopic: Prioritize hypotheses
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to prioritize hypoth…
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 prioritize hypotheses. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.