Health assessment · practice question

A 49-year-old client in the emergency department is being evaluated for nursing care related to general survey. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Using the clinical judgment model, what is the nurse's first step?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026health-assessment

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

Answer and explanation

Correct answer

A. 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 49-year-old client in the emergency department is being evaluated for nursing care related to general survey. Assessment data include pressure injury stage 2 noted on the coccyx with unchanged dressing. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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