Health Promotion and Maintenance
19. A child is seen in an emergency department following the ingestion of lighter fluid. Which nursing action is of the highest priority at this time?
Health Promotion and Maintenance
19. A child is seen in an emergency department following the ingestion of lighter fluid. Which nursing action is of the highest priority at this time?
. Induce vomiting.
. Determine the amount of poison ingested.
. Assess the respiratory system.
. Administer Mucomyst as ordered.
Test-Taking Tip
Any time a child ingests a poison, the nurse should first assess for aspiration.
Content Area: Child Health, Poisoning; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because inducing vomiting is contraindicated for the ingestion of a hydrocarbon. Answer 2 is incorrect because, although it is helpful to know the approximate amount of poison ingested, the highest priority upon admission is to assess the child for symptoms of aspiration. Answer 3 is correct because, when a child ingests a hydrocarbon such as lighter fluid, there is an immediate danger of aspiration. Therefore, the nurse's first priority is to assess the lungs. Answer 4 is incorrect because Mucomyst (N-acetylcysteine) is the treatment for an overdose of acetaminophen and is not indicated in the treatment of hydrocarbon ingestion.