Level: Foundational
Difficulty: Easy
Subtopic: Analyze cues
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to analyze cues. Ass…
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 analyze cues. Assessment data include the client improves after the initial intervention but develops a new safety concern. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that the client improves after the initial intervention but develops a new safety concern.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that the client improves after the initial intervention but develops a new safety concern.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that the client improves after the initial intervention but develops a new safety concern.
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.