Level: Foundational
Difficulty: Easy
Subtopic: Prioritize hypotheses
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to prioritize hypoth…
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 prioritize hypotheses. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.