Pediatric nursing · practice question
An 8-year-old child in the pediatric unit is being evaluated for newly diagnosed congenital heart disease. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. Which action should the nurse take first?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing
Answer and explanation
Correct answer
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Why
NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
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