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

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

Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Administer the next scheduled intervention before reassessing the client.

Answer and explanation

Correct answer

C. 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 trend recognition. 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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