A 4-year-old girl is brought to the emergency department. She has a "frog-like" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. Which nursing action is the priority for this patient?
A.
Maintain the airway.
B.
Obtain a throat culture.
C.
Start an intravenous line.
D.
Transport for a chest x-ray.
ANS: A
Airway, breathing, and circulation are the primary concerns for all patients. When a patient has acute respiratory distress, the most important nursing intervention is maintaining an airway. Starting an IV is important, but it is not the primary concern. Obtaining a throat culture would be contraindicated at this time, as it could cause vomiting or occlusion of the airway. The child should not be transported for x-ray; it should be done with portable equipment.
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