Health assessment · practice question

A 74-year-old client on a medical-surgical unit is being evaluated for respiratory assessment during hospitalization. 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 choiceMediumnclex-rn-bsnnclex-validatednclex-2026health-assessment

Evaluate discharge readiness before addressing acute findings.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.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 74-year-old client on a medical-surgical unit is being evaluated for respiratory assessment during hospitalization. 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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