Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
68. The lips and oral cavity of a child who ingested a corrosive substance are blistered, peeling, and swollen. The priority action for a nurse in the emergency department is to:
Test-Taking Tip
When dealing with corrosive substances, remember that they "burn both ways." Select "airway" as first priority in the ABCs (Airway, Breathing, Circulation).
Content Area: Child Health, Poisoning; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is incorrect because, while the child should be placed on NPO precautions to prevent further damage from the corrosive substance to the esophagus, it is not the nurse's first priority. Answer 2 is incorrect because, while the child is undoubtedly experiencing pain and will require an analgesic, it is not the nurse's first priority. Answer 3 is incorrect because corrosive substances burn as they go down the esophagus and will burn coming back up the esophagus with vomiting. Inducing vomiting (by any means) is contraindicated when dealing with the ingestion of corrosive substances. Answer 4 is correct because maintaining a patient airway is always the nurse's first priority. In the presence of swelling, the loss of a patent airway is both a real possibility and the nurse's first concern.
