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 evaluate outcomes. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which nursing action should the nurse take first?

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Tell the client symptoms are expected and avoid notifying the health care team.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Implement the final step of the care plan before assessing the client.Document the client as stable without reassessment.

Answer and explanation

Correct answer

B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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An RN prioritizing care after a change in status is being evaluated for nursing care related to evaluate outcomes. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which nursing action should the nurse take first?

Correct answer

Why

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