Ethics, legal nursing, delegation, prioritization · practice question

A 58-year-old client on a telemetry unit is being evaluated for nursing care related to advance directives. Assessment data include UAP reports the client fell in the bathroom. Using the clinical judgment model, what is the nurse's first step?

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Evaluate discharge readiness before addressing acute findings.Document the assessment at the end of the shift and continue the prior plan.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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A 58-year-old client on a telemetry unit is being evaluated for nursing care related to advance directives. Assessment data include UAP reports the client fell in the bathroom. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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