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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 CHR: 188RR: 46O2: 82 %What is the priority action for the nurse to take at this time?A. Keep the child calm and call for emergency airway equipmentB. Obtain IV accessC. Assess the throat for a cherry red epiglottisD. Place the child on a high flow nasal cannula at 100% FiO2

Question

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 CHR: 188RR: 46O2: 82 %What is the priority action for the nurse to take at this time?A. Keep the child calm and call for emergency airway equipmentB. Obtain IV accessC. Assess the throat for a cherry red epiglottisD. Place the child on a high flow nasal cannula at 100% FiO2

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Solution

The priority action for the nurse to take at this time is A. Keep the child calm and call for emergency airway equipment.

The child's symptoms - tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling - suggest a severe airway obstruction, possibly due to epiglottitis or another serious condition. The child's high heart rate (HR: 188), high respiratory rate (RR: 46), and low oxygen saturation (O2: 82%) further indicate respiratory distress.

In such a situation, maintaining the child's airway patency and ensuring oxygenation are the most critical steps. This involves keeping the child calm to prevent further airway obstruction and preparing for possible intubation or tracheostomy, hence the need for emergency airway equipment.

While the other options - obtaining IV access (B), assessing the throat for a cherry red epiglottis (C), and placing the child on a high flow nasal cannula at 100% FiO2 (D) - are also important in managing this patient, they are not the immediate priority.

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