Clinical judgment / Next Gen NCLEX case studies · practice question

An RN prioritizing care after a change in status is being evaluated for nursing care related to analyze cues. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Which action should the nurse take first?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026clinical-judgment-next-gen-nclex

Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.Wait for the provider's routine visit before acting on abnormal findings.Complete all remaining scheduled tasks before reassessing the client.Offer a warm blanket and reschedule assessment until after lunch.

Answer and explanation

Correct answer

A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Why

NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.

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An RN prioritizing care after a change in status is being evaluated for nursing care related to analyze cues. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Which action should the nurse take first?

Correct answer

Why

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