A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottis is suspected
In anticipation of the physician's prescriptions, number the following actions in the appropriate order for deliv-ering nursing interventions for this child. (Number 1 is the first action, and number 6 is the last action.) 1 Prepare for assisted ventilation and have necessary equipment available. 2 Obtain a pulse oximetry reading. 3 Obtain an axillary temperature. 4 Assess breath sounds by auscultation. 5 Obtain weight for correct antibiotic dose infusion. 6 Ask the mother about the precipitating events related to the child's condition.
1, 3, 4, 2, 5, 6
Rationale: The highest priority with epiglottis is to have assisted ventilation available, because the highest risk with this child is complete airway obstruction. Physiological interventions con-tinue to have the highest priority, with assessment of breath sounds and then obtaining pulse oximetry being next highest in priority. Once the airway is stabilized, the temperature can be ob-tained. At this time, the child should be stabilized and the weight can be obtained. The last prior-ity is asking about precipitating events, which is done once physiological needs are met.
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