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 matrix and bow-tie item reasoning. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which assessment approach should the nurse use first?

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

Defer assessment until all medications are administered.Use only the chart from admission without current data.Begin invasive procedures before any focused assessment.Screen for instability, then perform a focused assessment related to the presenting concern.

Answer and explanation

Correct answer

D. Screen for instability, then perform a focused assessment related to the presenting concern.

Why

Assessment begins with stability screening and focused data collection before invasive or delayed actions.

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An RN prioritizing care after a change in status is being evaluated for nursing care related to matrix and bow-tie item reasoning. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which assessment approach should the nurse use first?

Correct answer

Why

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