Comprehensive Year 2 BSN Clinical Judgment Review 2026/2027
UPDATE
1. Which phase of the NCSBN Clinical Judgment Measurement Model involves
identifying relevant information from various sources?
A. Recognize Cues
B. Analyze Cues
C. Prioritize Hypotheses
D. Generate Solutions
Answer: A
Rationale: Recognizing cues is the first step where the nurse identifies relevant data from
assessment, history, and lab results.
2. The nurse is caring for a patient with heart failure. Which clinical finding is the
most significant cue requiring immediate analysis?
A. Trace pedal edema
B. Pink frothy sputum
C. Fatigue after ambulation
D. Weight gain of 1 pound in 24 hours
Answer: B
Rationale: Pink frothy sputum is a classic sign of pulmonary edema, a life-threatening
complication of heart failure.
,3. When the nurse clusters data to determine the relationship between a
patient’s symptoms, which step of clinical judgment is being performed?
A. Analyze Cues
B. Prioritize Hypotheses
C. Take Action
D. Evaluate Outcomes
Answer: A
Rationale: Analyzing cues involves interpreting the data and organizing it into patterns or
clusters to see how it relates to the patient’s condition.
4. Which framework should the nurse use to prioritize multiple patient
hypotheses?
A. The Nursing Process
B. Maslow’s Hierarchy of Needs
C. SBAR Communication
D. Evidence-Based Practice
Answer: B
Rationale: Maslow’s Hierarchy and ABCs (Airway, Breathing, Circulation) are essential
frameworks for prioritizing which patient problem to address first.
5. The nurse is developing a plan of care for a patient with pneumonia. Which
action represents ‘Generating Solutions’?
A. Administering prescribed antibiotics
B. Auscultating lung sounds every 4 hours
C. Identifying expected outcomes such as clear breath sounds
D. Assessing the patient’s oxygen saturation
Answer: C
Rationale: Generating solutions involves planning and identifying goals or expected
outcomes based on prioritized hypotheses.
, 6. In the ‘Take Action’ phase of clinical judgment, which action is appropriate for
a patient in respiratory distress?
A. Analyzing the cause of the distress
B. Reviewing the patient’s past medical history
C. Determining if the oxygen helped after 30 minutes
D. Administering high-flow oxygen as prescribed
Answer: D
Rationale: ‘Take Action’ refers to the implementation of nursing interventions to address
the patient’s needs.
7. What is the primary purpose of the ‘Evaluate Outcomes’ step in the clinical
judgment model?
A. To gather more assessment data
B. To compare actual outcomes against expected outcomes
C. To delegate tasks to unlicensed assistive personnel
D. To document the interventions performed
Answer: B
Rationale: Evaluation determines the effectiveness of the nursing actions by comparing
the patient’s actual response to the expected outcomes.
8. A nurse receives a change-of-shift report. Which patient should the nurse
assess first?
A. A patient with a new onset of confusion and slurred speech
B. A patient with COPD and an oxygen saturation of 91%
C. A post-operative patient who has not voided for 4 hours
D. A patient with a pain score of 6/10 scheduled for physical therapy
Answer: A
UPDATE
1. Which phase of the NCSBN Clinical Judgment Measurement Model involves
identifying relevant information from various sources?
A. Recognize Cues
B. Analyze Cues
C. Prioritize Hypotheses
D. Generate Solutions
Answer: A
Rationale: Recognizing cues is the first step where the nurse identifies relevant data from
assessment, history, and lab results.
2. The nurse is caring for a patient with heart failure. Which clinical finding is the
most significant cue requiring immediate analysis?
A. Trace pedal edema
B. Pink frothy sputum
C. Fatigue after ambulation
D. Weight gain of 1 pound in 24 hours
Answer: B
Rationale: Pink frothy sputum is a classic sign of pulmonary edema, a life-threatening
complication of heart failure.
,3. When the nurse clusters data to determine the relationship between a
patient’s symptoms, which step of clinical judgment is being performed?
A. Analyze Cues
B. Prioritize Hypotheses
C. Take Action
D. Evaluate Outcomes
Answer: A
Rationale: Analyzing cues involves interpreting the data and organizing it into patterns or
clusters to see how it relates to the patient’s condition.
4. Which framework should the nurse use to prioritize multiple patient
hypotheses?
A. The Nursing Process
B. Maslow’s Hierarchy of Needs
C. SBAR Communication
D. Evidence-Based Practice
Answer: B
Rationale: Maslow’s Hierarchy and ABCs (Airway, Breathing, Circulation) are essential
frameworks for prioritizing which patient problem to address first.
5. The nurse is developing a plan of care for a patient with pneumonia. Which
action represents ‘Generating Solutions’?
A. Administering prescribed antibiotics
B. Auscultating lung sounds every 4 hours
C. Identifying expected outcomes such as clear breath sounds
D. Assessing the patient’s oxygen saturation
Answer: C
Rationale: Generating solutions involves planning and identifying goals or expected
outcomes based on prioritized hypotheses.
, 6. In the ‘Take Action’ phase of clinical judgment, which action is appropriate for
a patient in respiratory distress?
A. Analyzing the cause of the distress
B. Reviewing the patient’s past medical history
C. Determining if the oxygen helped after 30 minutes
D. Administering high-flow oxygen as prescribed
Answer: D
Rationale: ‘Take Action’ refers to the implementation of nursing interventions to address
the patient’s needs.
7. What is the primary purpose of the ‘Evaluate Outcomes’ step in the clinical
judgment model?
A. To gather more assessment data
B. To compare actual outcomes against expected outcomes
C. To delegate tasks to unlicensed assistive personnel
D. To document the interventions performed
Answer: B
Rationale: Evaluation determines the effectiveness of the nursing actions by comparing
the patient’s actual response to the expected outcomes.
8. A nurse receives a change-of-shift report. Which patient should the nurse
assess first?
A. A patient with a new onset of confusion and slurred speech
B. A patient with COPD and an oxygen saturation of 91%
C. A post-operative patient who has not voided for 4 hours
D. A patient with a pain score of 6/10 scheduled for physical therapy
Answer: A
