Safe, Effective Care Environment
35. A nurse in an emergency department performs triage of clients in the waiting room. Which child should the nurse send for immediate examination?
Safe, Effective Care Environment
35. A nurse in an emergency department performs triage of clients in the waiting room. Which child should the nurse send for immediate examination?
. A 1-month-old infant crying vigorously with a history of frequent sneezing.
. A 2-year-old child with fever and urinary frequency.
. A 6-month-old infant with a sunken fontanel and history of poor feeding.
. A 9-year-old with complaints of pain and a possible arm fracture.
Test-Taking Tip
Follow the ABCs for prioritization. If all of the children have stable airways, look for the child that is at risk of circulatory collapse. In this case, the 6-month-old infant is at greatest risk due to age and history.
Content Area: Child Health, Fluid and Electrolyte Imbalances; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because frequent sneezing is a normal finding in young infants when they attempt to clear the airway of secretions. Since the child is crying vigorously, oxygenation appears satisfactory at this time. Answer 2 is incorrect because, although the child is at risk for dehydration due to frequent voiding and fever, a 2-year-old child is better able to compensate for dehydration than an infant, and the child may also have adequate oral intake. Answer 3 is correct because the infant's history and assessment findings are suggestive of moderate to severe dehydration, which should be addressed quickly. Answer 4 is incorrect because, although the child's pain control is a concern, dehydration is the top priority.