Level: Advanced
Difficulty: Hard
Subtopic: Safety-focused judgment
NCLEX: The nurse reviewing updated assessment data is being evaluated for nursing care related to safety-focused judgmen…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
The nurse reviewing updated assessment data is being evaluated for nursing care related to safety-focused judgment. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.