Pathophysiology · practice question

A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to electrolyte imbalance. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Using the clinical judgment model, what is the nurse's first step?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pathophysiology

Evaluate discharge readiness before addressing acute findings.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.Document the assessment at the end of the shift and continue the prior plan.

Answer and explanation

Correct answer

B. 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 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to electrolyte imbalance. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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