Level: Foundational
Difficulty: Easy
Subtopic: Growth and development
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. 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. Administer the next scheduled intervention before reassessing the client.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Administer the next scheduled intervention before reassessing the client.
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.