Pediatric nursing · practice question

A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which nursing action should the nurse take first?

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

Implement the final step of the care plan before assessing the client.Document the client as stable without reassessment.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Administer the next scheduled intervention before reassessing the client.

Answer and explanation

Correct answer

C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which nursing action should the nurse take first?

Correct answer

Why

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