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.

The nurse should cover the child’s wounds with a clean, dry cloth;

however, there is a different action the nurse should take first.

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

The nurse should establish IV access for the child using a large-bore

catheter; however, there is a different action the nurse should take

first.

C. Provide reassurance to the child's parents.

The nurse should provide reassurance to the child’s parents; however,

there is a different action the nurse should take first.

D. 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.