Level: Foundational
Difficulty: Easy
Subtopic: Pediatric vital signs
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for febrile illness in a toddler. Assessment data in…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for febrile illness in a toddler. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.