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 new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Which finding requires the nurse to intervene immediately?

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A comfort request with unchanged vital signs and no new symptoms.A stable, long-standing finding that matches the expected care plan.The new finding that new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion.Routine data unchanged from the prior assessment.

Answer and explanation

Correct answer

C. The new finding that new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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