Nursing fundamentals · practice question

A 70-year-old client in a rehabilitation facility is being evaluated for high fall risk on a medical unit. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Using the clinical judgment model, what is the nurse's first step?

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

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 high fall risk on a medical unit. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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