Pediatric nursing · practice question

A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. Which nursing action is the priority to keep the client safe?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pediatric-nursing

Apply the first intervention in the policy manual without a current assessment.Tell the client symptoms are expected and avoid notifying the health care team.Leave the client alone to promote independence while finishing charting.Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Answer and explanation

Correct answer

D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Why

Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.

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A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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