Level: Advanced
Difficulty: Hard
Subtopic: Child safety
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for pediatric injury prevention. Assessment d…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for pediatric injury prevention. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that nasal flaring, grunting, retractions, and SpO2 89%.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that nasal flaring, grunting, retractions, and SpO2 89%.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that nasal flaring, grunting, retractions, and SpO2 89%.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.