Difficulty: Medium
Average Score: 80%
Simulated
Passage / Scenario
A 2-year-old child who has a high fever, severe dyspnea, and is droolingA nurse in an emergency department is assessing a 2-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?
Correct answer
C
Rationale
The correct answer is C: Prepare for nasotracheal intubation. This is the priority action as the child's symptoms indicate a potential airway obstruction, which can be life-threatening. Nasotracheal intubation helps secure the airway and ensure adequate oxygenation and ventilation. Obtaining blood culture specimens (A) can be important but not as immediate as ensuring airway patency. Administering an antipyretic (B) may help reduce fever but does not address the urgent need for airway management. Inserting an IV catheter (D) is important for fluid administration but is not the immediate priority over securing the airway.