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 toddler

years. 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."

d. "Your child should be able to scribble spontaneously using a crayon at the age of

15

months."

Rationale: The nurse should teach the parent that at the age of 15 months, the toddler should be

able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make

strokes imitatively.