Hard

A hospitalised child becomes pale and restless. The heart rate rises from 96 to 138 beats per minute, the hands are cool, and capillary refill is delayed. Which nursing action is the priority?

Correct answer: C. Assess circulation and immediately notify the nurse in charge

  • A. Offer oral fluids and recheck after one hour
  • B. Document the findings at the end of the shift
  • C. Assess circulation and immediately notify the nurse in charge
  • D. Provide a quiet activity to reduce the child’s anxiety

Explanation

The combination of tachycardia, pallor, cool extremities and delayed capillary refill suggests impaired circulation and possible shock. Circulation takes priority over comfort or routine documentation, so prompt assessment and escalation are required.

Submitted by a TestUstad contributor and published by the TestUstad editorial teamLast updated
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About Care of the Hospitalised Child

Care of the hospitalised child covers admission assessment, monitoring vital signs, medication safety, pain relief, nutrition, hygiene, infection prevention and safe discharge planning. It also addresses atraumatic care, therapeutic play, communication with children and parents, family participation, separation anxiety, safeguarding and the child’s rights during hospital care.

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