Level: Advanced
Difficulty: Hard
Subtopic: Safety-focused judgment
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to safety-focused ju…
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 safety-focused judgment. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.