Level: Clinical
Difficulty: Medium
Subtopic: Dehydration
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for dehydration from vomiting and diarrhea. Asses…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for dehydration from vomiting and diarrhea. 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. Tell the client symptoms are expected and avoid notifying the health care team.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
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.