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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."

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