Level: Clinical
Difficulty: Medium
Subtopic: Take action
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to take action. Asse…
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 take action. Assessment data include the medication record, labs, and assessment notes contain conflicting cues. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that the medication record, labs, and assessment notes contain conflicting cues.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that the medication record, labs, and assessment notes contain conflicting cues.
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.