Level: Foundational
Difficulty: Easy
Subtopic: Fluid volume excess and deficit
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to fluid volume exces…
Pathophysiology Clinical Judgment Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to fluid volume excess and deficit. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.