Level: Clinical
Difficulty: Medium
Subtopic: Medication dosing by weight
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for weight-based pediatric medication. Assess…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for weight-based pediatric medication. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: B. 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.