A patient with pneumonia becomes newly confused and has cool, mottled skin. The blood pressure is 86/52 mmHg and the respiratory rate is 30 per minute. Which action is the priority?
Correct answer: B. Escalate immediately for urgent clinical assessment
- A. Complete the routine evening hygiene care
- B. Escalate immediately for urgent clinical assessment
- C. Ask the family to remain quietly at the bedside
- D. Recheck the blood pressure after the next meal
Explanation
New confusion, hypotension, mottled skin, and tachypnoea indicate possible shock and severe deterioration. Immediate escalation is needed so that assessment and time-critical treatment can begin; routine care must wait.
Report an error
The more specific you are, the faster it gets fixed. A source beats an opinion.
Prefer email? support@testustad.com
About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
Practise Clinical Judgement and Prioritisation
50 free Clinical Judgement and Prioritisation MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.
Discussion
Stuck on an option, or know a faster way to get there? Ask or explain it here.
No comments yet. Be the first to explain this one.
Exams that ask International Nursing Practice questions like this
International Nursing Practice is on 2 papers prepared for on TestUstad, and all of them draw the same bank, so this question is worth knowing for every one of them.
More Clinical Judgement and Prioritisation questions
A patient who had abdominal surgery has sudden shortness of breath, sharp chest pain, and a heart rate of 132 per minute. Oxygen saturation is falling. What should the nurse do first?
A patient with diabetes is awake, sweating, and confused. A bedside glucose reading confirms hypoglycaemia, and the patient can swallow safely. What should the nurse do first?
A patient receiving a blood transfusion reports chills, lower back pain, and chest tightness. What is the nurse's first action?
A patient reports dizziness when standing two days after starting treatment for hypertension. The patient is alert, has no chest pain, and is currently sitting safely. What should the nurse do first?
A patient with a lower-leg cast reports worsening pain despite prescribed analgesia. The toes are pale, cool, and difficult to move. What should the nurse do first?
A patient with vomiting has a potassium level reported as critically low and now reports palpitations. The cardiac monitor shows an irregular rhythm. What should the nurse do first?