Clinical judgment / Next Gen NCLEX case studies · practice question

The nurse reviewing updated assessment data is being evaluated for nursing care related to case study unfolding data. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Before teaching, what should the nurse assess first?

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Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.Begin a long lecture while the client is in acute distress.Assume understanding without checking literacy or readiness.Delegate all teaching without RN evaluation of learning needs.

Answer and explanation

Correct answer

A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.

Why

Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.

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The nurse reviewing updated assessment data is being evaluated for nursing care related to case study unfolding data. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. Before teaching, what should the nurse assess first?

Correct answer

Why

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