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. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.