Level: Clinical
Difficulty: Medium
Subtopic: Congenital disorders
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for newly diagnosed congenital heart disease. Assess…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for newly diagnosed congenital heart disease. Assessment data include pulling at ears and crying with tugging on the right ear. Which error is most dangerous on the NCLEX and in practice?
Question
A. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
B. Teaching the client after stability is confirmed.
C. Reassessing the client after an appropriate intervention.
D. Using SBAR to notify the provider about abnormal findings.
Rationale
Correct answer: A. 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.