Pediatric nursing · practice question
A 2-year-old toddler in the emergency department is being evaluated for family presence during hospitalization. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which nursing action is the priority to keep the client safe?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
A. 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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