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ATI Nursing Care of Children Proctored Exam 2021
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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 p...
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