Adult health / medical-surgical nursing · practice question

A 68-year-old client on a medical-surgical unit is being evaluated for pancytopenia after chemotherapy. 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?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg

Evaluate discharge readiness before addressing acute findings.Document the assessment at the end of the shift and continue the prior plan.Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.Implement the first intervention on the existing care plan without reviewing new data.

Answer and explanation

Correct answer

C. 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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A 68-year-old client on a medical-surgical unit is being evaluated for pancytopenia after chemotherapy. 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?

Correct answer

Why

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