Clinical judgment is the cornerstone of safe nursing practice, and it’s now the central focus of the Next Generation NCLEX (NGN). The NCSBN Clinical Judgment Measurement Model (NCJMM) identifies six cognitive skills that every nurse must master. Understanding these skills isn’t just essential for passing the NCLEX—it’s foundational for your entire nursing career.
In this in-depth guide, we’ll explore each of the six clinical judgment skills, provide practical examples, and share strategies to strengthen your clinical reasoning abilities.
What is Clinical Judgment in Nursing?
Clinical judgment is the process nurses use to make decisions about patient care. It involves:
- Observing and interpreting patient data
- Applying nursing knowledge to clinical situations
- Making decisions under uncertainty
- Taking appropriate action
- Evaluating outcomes
The NCSBN developed the Clinical Judgment Measurement Model through extensive research involving over 100 nursing experts and analysis of data from more than 200,000 NCLEX candidates. This model provides the framework for NGN test items and case studies.
The 6 Cognitive Skills of Clinical Judgment
Skill 1: Recognize Cues
Definition: The ability to identify relevant and important information from different sources, including patient assessment data, history, medical records, and diagnostic results.
What This Looks Like in Practice:
- Noticing changes in vital signs
- Identifying abnormal lab values
- Observing changes in patient behavior or symptoms
- Recognizing relevant information in patient history
NCLEX Question Example:
A nurse is reviewing the chart of a patient admitted with heart failure. Which findings should the nurse identify as relevant to the patient’s current condition? (Select all that apply)
Tips for Recognizing Cues:
- Know normal values for vital signs, labs, and assessments
- Look for patterns and clusters of symptoms
- Consider what’s relevant to the specific diagnosis
- Don’t overlook subtle changes
Skill 2: Analyze Cues
Definition: The ability to connect and interpret the meaning of collected data, determining what the information indicates about the patient’s condition.
What This Looks Like in Practice:
- Connecting symptoms to potential diagnoses
- Understanding how different findings relate to each other
- Determining the significance of abnormal findings
- Distinguishing expected from unexpected findings
NCLEX Question Example:
A patient’s blood pressure is 88/56 mmHg, heart rate is 118 bpm, and urine output is 20 mL over the past hour. The nurse analyzes these findings and recognizes they indicate:
Tips for Analyzing Cues:
- Look for relationships between findings
- Consider pathophysiology
- Think about expected vs. unexpected presentation
- Use clinical reasoning chains (if this, then that)
Skill 3: Prioritize Hypotheses
Definition: The ability to rank potential problems or conditions based on urgency, likelihood, and risk to the patient.
What This Looks Like in Practice:
- Determining which problem needs attention first
- Ranking potential diagnoses by probability
- Identifying life-threatening vs. non-urgent concerns
- Using prioritization frameworks (ABCs, Maslow)
NCLEX Question Example:
Based on the assessment findings, which potential problem should the nurse address first?
Tips for Prioritizing Hypotheses:
- Use ABCs (Airway, Breathing, Circulation)
- Apply Maslow’s Hierarchy of Needs
- Consider acute vs. chronic problems
- Actual problems before potential problems
- Life-threatening before non-life-threatening
Skill 4: Generate Solutions
Definition: The ability to identify expected outcomes and interventions that address the prioritized problems.
What This Looks Like in Practice:
- Planning appropriate nursing interventions
- Identifying desired patient outcomes
- Selecting evidence-based treatments
- Considering available resources
NCLEX Question Example:
The nurse is caring for a patient experiencing respiratory distress. Which interventions should the nurse include in the plan of care? (Select all that apply)
Tips for Generating Solutions:
- Match interventions to the priority problem
- Consider the patient’s specific situation
- Think about nursing scope of practice
- Include both independent and collaborative interventions
Skill 5: Take Action
Definition: The ability to implement the interventions that address the highest priorities.
What This Looks Like in Practice:
- Performing nursing interventions
- Administering medications safely
- Communicating with the healthcare team
- Documenting actions taken
NCLEX Question Example:
The patient’s oxygen saturation has dropped to 88%. Which action should the nurse take first?
Tips for Taking Action:
- Focus on the FIRST or PRIORITY action
- Consider patient safety
- Think about what requires an order vs. independent nursing action
- Remember: assess before intervening (usually)
Skill 6: Evaluate Outcomes
Definition: The ability to assess the effectiveness of interventions and compare actual outcomes to expected outcomes.
What This Looks Like in Practice:
- Reassessing after interventions
- Determining if goals were met
- Identifying need for plan modification
- Recognizing improvement or deterioration
NCLEX Question Example:
After administering the prescribed medication, which finding indicates the intervention was effective?
Tips for Evaluating Outcomes:
- Know expected outcomes for interventions
- Compare current status to baseline
- Consider timeframes for expected changes
- Be prepared to modify the plan if needed
How Clinical Judgment Appears on the NGN
On the Next Generation NCLEX, clinical judgment is measured through:
Unfolding Case Studies
Each case study contains six questions, with each question measuring one of the six cognitive skills. The case “unfolds” as you progress, presenting new information that may change your clinical reasoning.
Standalone Items
Individual questions (including bow-tie, trend, and matrix items) that measure specific clinical judgment skills.
Practice Exercise: Applying the 6 Skills
Scenario: Mrs. Johnson, 72 years old, is admitted with pneumonia. She has a history of COPD and heart failure.
1. Recognize Cues: Temperature 101.8°F, SpO2 89% on room air, productive cough with yellow sputum, crackles in lower lobes, HR 98, BP 142/88.
2. Analyze Cues: Elevated temperature and productive cough suggest infection. Low oxygen saturation and crackles indicate respiratory compromise. Vital signs suggest the body is compensating.
3. Prioritize Hypotheses: Priority problems: (1) Impaired gas exchange, (2) Infection, (3) Risk for fluid volume excess (given HF history).
4. Generate Solutions: Administer prescribed oxygen, antibiotics, and monitor respiratory status. Position for optimal breathing. Teach coughing and deep breathing.
5. Take Action: First action: Apply supplemental oxygen to address the priority problem of impaired gas exchange.
6. Evaluate Outcomes: Expected outcome: SpO2 ≥92%, decreased work of breathing, temperature trending down within 48 hours.
Strengthening Your Clinical Judgment
To improve your clinical judgment skills:
- Practice with case studies: Work through scenarios that require you to use all six skills
- Review pathophysiology: Understanding disease processes helps you analyze cues
- Study prioritization frameworks: ABCs, Maslow, and nursing process
- Learn from rationales: Understand why answers are correct or incorrect
- Think like a nurse: Always consider patient safety and evidence-based practice
Mastering clinical judgment takes practice, but it’s a skill that will serve you throughout your nursing career—starting with passing the NCLEX.
