Adult health / medical-surgical nursing · practice question
A 68-year-old client on a medical-surgical unit is being evaluated for chronic kidney disease with fluid overload. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Using the clinical judgment model, what is the nurse's first step?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg
Answer and explanation
Correct answer
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Why
NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
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