Pediatric nursing · practice question
An 8-year-old child in the pediatric unit is being evaluated for dehydration from vomiting and diarrhea. 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 choiceMediumnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
A. 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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