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. The nurse reviews…
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. The nurse reviews this trend: urine output decreased and capillary refill increased from 2 to 4 seconds. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
C. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: B. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.