Pediatric nursing · practice question
A 2-year-old toddler in the emergency department is being evaluated for febrile illness in a toddler. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Using the clinical judgment model, what is the nurse's first step?
Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Why
NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
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