A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products.

The child has a chemical smell on their hands, face, and clothes.
After ensuring the airway is patent, which action should the nurse take first?

Choice A rationale
When a client’s blood pressure cannot be measured due to casts on both arms and the client’s position, the most appropriate action for the nurse is to document why the blood pressure cannot be accurately measured at the present time. This is because accurate measurement of blood pressure is crucial for monitoring the client’s health status and making appropriate clinical decisions. If the blood pressure cannot be measured accurately, it is important to document this fact along with the reasons why, so that other healthcare professionals are aware of the situation and can take appropriate action.
Choice B rationale
Advising the UAP to document the last blood pressure obtained on the client’s graphic sheet is not the most appropriate action in this situation. While it might provide some information about the client’s previous blood pressure readings, it does not address the current inability to measure the blood pressure. Furthermore, it could potentially lead to confusion or misinterpretation of the client’s current health status.
Choice C rationale
Demonstrating how to palpate the popliteal pulse with the client supine and the knee flexed is not the most appropriate action in this situation. While palpating the popliteal pulse can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this action might not be feasible or appropriate depending on the client’s condition and the presence of casts on both arms.
Choice D rationale
Estimating the blood pressure by assessing the pulse volume of the client’s radial pulses is not the most appropriate action in this situation. While pulse volume can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this method of estimating blood pressure is not as accurate or reliable as direct measurement.

Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.