Nursing fundamentals · practice question

A 70-year-old client in a rehabilitation facility is being evaluated for postoperative monitoring. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. 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.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.

Answer and explanation

Correct answer

C. 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 70-year-old client in a rehabilitation facility is being evaluated for postoperative monitoring. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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