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 medication record, labs, and assessment notes contain conflicting cues. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Administer the next scheduled intervention before reassessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Administer the next scheduled intervention before reassessing the client.
Rationale
Correct answer: C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.