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 assessment approach should the nurse use first?

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

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

Answer and explanation

Correct answer

B. 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 analyze cues. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Which assessment approach should the nurse use first?

Correct answer

Why

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