In the fifth step of the CJMM, Take Action, what does the nurse do?

• A. Implement identified interventions and prioritize highest priority issues first
• B. Reassess the patient with updated data
• C. Plan for discharge and follow-up
• D. Collect data for evaluating outcomes

Answer: (A)

Take Action focuses on turning assessment findings into care by implementing the identified interventions and prioritizing the most critical issues first. When it’s time to act, the nurse carries out the planned interventions, initiates necessary treatments, mobilizes needed resources, and continuously monitors the patient’s response, adjusting as needed to prevent deterioration. This proactive, prioritized approach keeps the plan moving forward and ensures the most urgent needs are addressed promptly. Reassessing with updated data fits into evaluating how well the actions worked and guiding any adjustments; planning for discharge and follow-up happens later in the care process; collecting data for evaluating outcomes is part of the evaluation phase used to determine effectiveness and inform future care. For example, if a patient shows respiratory distress, act quickly by ensuring airway and oxygenation, delivering treatments as ordered, calling for help, and then reassessing to gauge improvement.