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