Nursing care of the child with a snake bite involves assessment of the child for initial and progressive signs of envenomation. Which is the priority nursing action at this time?
1. Measure the circumference of the extremity containing the bite every 20 to 30 minutes.
2. Assess immunization status.
3. Assess the need for emergency breathing interventions.
4. Assess neurovascular status and vital signs.
5. Assess pain and the child's response to pain medication.
3
Rationale 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.
Rationale 2: Immunization status is important information to obtain, but the more immediate need is for airway, breathing, and circulation.
Rationale 3: Emergency intervention for airway, breathing, and circulation take priority and has a high probability of occurrence.
Rationale 4: Vital signs and neurovascular status of the distal extremities should be monitored but do not take priority over airway, breathing, and circulation.
Rationale 5: 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.
Global Rationale:
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