Level: Clinical
Difficulty: Medium
Subtopic: Dehydration
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for dehydration from vomiting and diarrhea. Asses…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for dehydration from vomiting and diarrhea. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale
Correct answer: D. 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.