Level: Foundational
Difficulty: Easy
Subtopic: Pediatric vital signs
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for febrile illness in a toddler. Assessment data…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for febrile illness in a toddler. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale
Correct answer: D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.