Nursing fundamentals · practice question

A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to hygiene and comfort. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Using the clinical judgment model, what is the nurse's first step?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals

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

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 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to hygiene and comfort. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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