Level: Advanced
Difficulty: Hard
Subtopic: Pediatric pain
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for postoperative pain in a school-age child. Assess…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for postoperative pain in a school-age child. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Apply restraints without assessing less restrictive safety options first.
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
C. Apply the first intervention in the policy manual without a current assessment.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.