Level: Clinical
Difficulty: Medium
Subtopic: Congenital disorders
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for newly diagnosed congenital heart disease….
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for newly diagnosed congenital heart disease. The nurse reviews this trend: temperature increased from 100.4°F (38°C) to 103.1°F (39.5°C) with a petechial rash. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.