Clinical judgment / Next Gen NCLEX case studies · practice question

The nurse reviewing updated assessment data is being evaluated for nursing care related to take action. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Using the clinical judgment model, what is the nurse's first step?

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Document the assessment at the end of the shift and continue the prior plan.Evaluate discharge readiness before addressing acute findings.Implement the first intervention on the existing care plan without reviewing new data.Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.

Answer and explanation

Correct answer

D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.

Why

NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.

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The nurse reviewing updated assessment data is being evaluated for nursing care related to take action. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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