Level: Clinical
Difficulty: Medium
Subtopic: Evaluate outcomes
NCLEX: The nurse reviewing updated assessment data is being evaluated for nursing care related to evaluate outcomes. Ass…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
The nurse reviewing updated assessment data is being evaluated for nursing care related to evaluate outcomes. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.