Level: Foundational
Difficulty: Easy
Subtopic: Medication dosing by weight
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for weight-based pediatric medication. Assessment…
Pediatric nursing Clinical Judgment Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for weight-based pediatric medication. Assessment data include parents report decreased wet diapers and lethargy over 24 hours. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.