Difficulty: Medium
Average Score: 87%
Simulated
Passage / Scenario
The nurse is assessing a 4-year old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are: Temp: 39 C (102.2 F), HR: 188, RR: 46, O2: 81%.What is the priority action for the nurse to take at this time?
Correct answer
A
Rationale
The correct answer is A: Keep the child calm and call for emergency airway equipment. This is the priority action because it addresses the immediate need to ensure the child's airway is maintained. By keeping the child calm, the nurse can prevent further distress that might compromise the airway. Calling for emergency airway equipment allows for prompt intervention if the child's condition deteriorates. Assessing for a cherry red epiglottis (B) is important but not as urgent as ensuring airway patency. Placing the child in a knee to chest position (C) is not indicated for airway emergencies. Obtaining IV access and starting IV fluids (D) can be done after securing the airway.