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 the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which nursing action should the nurse take first?

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Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the finding and recheck at the end of the shift without further assessment.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.

Answer and explanation

Correct answer

A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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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 the exhibit shows rising oxygen needs, new crackles, and decreasing urine output. Which nursing action should the nurse take first?

Correct answer

Why

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