Level: Foundational
Difficulty: Easy
Subtopic: Medication dosing by weight
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for weight-based pediatric medication. Assessment da…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for weight-based pediatric medication. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that nasal flaring, grunting, retractions, and SpO2 89%.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that nasal flaring, grunting, retractions, and SpO2 89%.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that nasal flaring, grunting, retractions, and SpO2 89%.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.