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.
Category | NR & NUR Exams |
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