Which is the priority nursing action when providing care to a child who is bitten by a snake?
1. Measuring the circumference of the extremity twice per hour
2. Monitoring respiratory status
3. Assessing vital signs
4. Evaluating response to pain medication
2
Explanation:
1. In order to track progression in swelling and response to treatment, the extremity with the bite is measured every 20 to 30 minutes. However, this does not take priority over airway, breathing, and circulation.
2. Emergency intervention for airway, breathing, and circulation takes priority and has a high probability of occurrence.
3. Vital signs and neurovascular status of the distal extremities should be monitored but do not take priority over airway, breathing, and circulation.
4. Pain medication will need to be given and the response to the treatment monitored; however, this should not take priority over airway, breathing, and circulation.
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