Level: Clinical
Difficulty: Medium
Subtopic: Respiratory illness
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for bronchiolitis with respiratory distress. Assessm…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for bronchiolitis with respiratory distress. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: A. 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.