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 new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. 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 new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion.
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 new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion.
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 new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion.
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.