Nutrition · practice question

A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to hydration and fluid balance. Assessment data include the client receives enteral feeding and develops abdominal distention with nausea. Using the clinical judgment model, what is the nurse's first step?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026nutrition

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.Implement the first intervention on the existing care plan without reviewing new data.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 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to hydration and fluid balance. Assessment data include the client receives enteral feeding and develops abdominal distention with nausea. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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