Level: Clinical
Difficulty: Medium
Subtopic: Respiratory illness
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for bronchiolitis with respiratory distress. Asse…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for bronchiolitis with respiratory distress. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. 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. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
B. Reassessing the client after an appropriate intervention.
C. Choosing an intervention before identifying assessment cues and immediate safety risk.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: C. 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.