The telephone triage nurse receives a call from a parent who states that her 18-month-old is making a crowing sound when he breathes and is hard to wake up. Which is the nurse's priority action?
1. Obtain the history of the illness from the parent.
2. Advise the parent to hang up and call 911.
3. Make an appointment for the child to see the health care provider.
4. Reassure the parent and provide instructions on home care for the child.
2
Rationale:
1. Obtaining the history is appropriate only after the child has received emergency treatment to control the airway.
2. The nurse should immediately recognize the symptoms of severe upper respiratory distress and advise the parent to call 911. Crowing is heard when there is severe narrowing of the airway.
3. Making an appointment would be appropriate in non-emergency situations.
4. Home care is not appropriate, as a crowing sound at rest with a change in the level of consciousness makes this an emergency situation for 911.
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