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. Using ABCs and Maslow, which need should the nurse address first?

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

Visitor concerns before physiologic stability.Airway, breathing, and circulation problems before comfort or psychosocial needs.Long-term teaching before treating acute physiologic risk.Pain relief before checking airway and breathing.

Answer and explanation

Correct answer

B. Airway, breathing, and circulation problems before comfort or psychosocial needs.

Why

Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.

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