A nurse in the emergency department is caring for a 2-year-old child who

was found by his parents crying and holding a container of toilet bowl

cleaner. The child's lips are edematous and inflamed, and he is drooling.

Which of the following is the priority action by the nurse?

a. Remove the child's contaminated clothing.

b. Check the child's respiratory status.

c. Administer an antidote to the child.

d. Establish IV access for the child.

Rationale: The nurse should apply the ABC priority-setting framework when

answering this item. This framework emphasizes the basic core of human

functioning: having an open airway, being able to breathe in adequate

amounts of oxygen, and circulating oxygen to the body's organs via the

blood. An alteration in any of these can indicate a threat to life, and is

therefore the nurse’s priority concern. When applying the ABC priority setting

framework, airway is always the highest priority because the airway must be

clear and open for oxygen exchange to occur. Breathing is the second

highest priority in the ABC priority setting framework because adequate

ventilatory effort is essential in order for oxygen exchange to occur.

Circulation is the third highest priority in the ABC priority setting framework

because delivery of oxygen to critical organs only occurs if the heart and

blood vessels are capable of efficiently carrying oxygen to them. The nurse

observes that the child’s lips are edematous and inflamed and that he is

drooling. These findings indicate that the child might have swelling of the

oral cavity and pharynx, which can result in a compromised airway.

2. A nurse is teaching a parent of a 12-month old child about development

during the toddleryears. Which of the following statements should the nurse

include?

a. "Your child should be referring to himself using the appropriate

pronoun by 18 months of age."

b. "A toddler's interest in looking at pictures occurs at 20 months of

age."

c. "A toddler should have daytime control of his bowel and bladder by

24 months of age."