Level: Foundational
Difficulty: Easy
Subtopic: Recognize cues
NCLEX: The nurse reviewing updated assessment data is being evaluated for unfolding changes in a case study. Assessment…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
The nurse reviewing updated assessment data is being evaluated for unfolding changes in a case study. Assessment data include the client improves after the initial intervention but develops a new safety concern. Which nursing action is the priority to keep the client safe?
Question
A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: A. 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.