Level: Foundational
Difficulty: Easy
Subtopic: Generate solutions
NCLEX: A client in an unfolding case study is being evaluated for nursing care related to generate solutions. Assessment…
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 generate solutions. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that the exhibit shows rising oxygen needs, new crackles, and decreasing urine output.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that the exhibit shows rising oxygen needs, new crackles, and decreasing urine output.
Rationale
Correct answer: D. The new finding that the exhibit shows rising oxygen needs, new crackles, and decreasing urine output.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.