Clinical judgment / Next Gen NCLEX case studies · practice question

The nurse reviewing updated assessment data is being evaluated for nursing care related to evaluate outcomes. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which action should the nurse take first?

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Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.Offer a warm blanket and reschedule assessment until after lunch.Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.Complete all remaining scheduled tasks before reassessing the client.

Answer and explanation

Correct answer

C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.

Why

NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.

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The nurse reviewing updated assessment data is being evaluated for nursing care related to evaluate outcomes. Assessment data include the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which action should the nurse take first?

Correct answer

Why

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