1. A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first?

A. Cover the child's wounds with a clean, dry cloth.

B. Establish IV access for the child with a large-bore catheter.

C. Provide reassurance to the child's parents. D. Determine the child's breathing pattern.

Determine the child's breathing pattern.

The nurse should apply the ABC priority setting framework. 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. Determining the child's breathing pattern is the first action the nurse should take. 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.

2. A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching?

A. "My child should consume 1,000 calories per day."

B. "My child should have 4 ounces of protein per day."

C. "I should give my child 32 ounces (4 cups) of milk per day."

D. "I should feed my child 4 ounces (1/2 cup) of vegetables per day." "My child should consume 1,000 calories per day."

Toddlers who are 2 years old should consume 1,000 calories daily.

3. A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?

A. "I will take my child's rectal temperature daily."

B. "I will make sure my child gets his MMR vaccine this week." C. "I will inspect my child's mouth every day for sores."

D. "I will allow my child to ride his bicycle tomorrow." "I will inspect my child's mouth every day for sores."

A child who has leukemia is at an increased risk for mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations.

4. A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make?

A. "The test determines the level of antibiotics in your child's blood."

B. "The test tells us if your child ever had the measles."

C. "The test verifies the amount of albumin in your child's blood." D. "The test shows us if your child had a recent strep infection."

"The test shows us if your child had a recent strep infection."