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
While the color, clarity, and odor of urine can provide important information about a patient’s overall health and hydration status, it is not the most crucial information to obtain before inserting an indwelling urinary catheter.
Choice B rationale
The patient’s ability to increase fluid intake can be important in managing various health conditions, but it is not the most important information to obtain before this procedure.
Choice C rationale
Knowing if a patient has allergies to antiseptic solutions is crucial before inserting an indwelling urinary catheter. Using an antiseptic solution that a patient is allergic to can lead to serious complications.
Choice D rationale
While a previous history of urinary tract infections can inform the care and management of a patient with an indwelling urinary catheter, it is not the most important information to obtain before the procedure.

Choice A rationale
For a client who has been intubated and is on a ventilator due to sepsis, the most appropriate action based on the client’s status would be to continue weaning the ventilator as ordered.
Weaning is the process of gradually reducing ventilator support, and it is typically initiated once the underlying cause of respiratory failure has been addressed. In this case, if the client’s condition has stabilized and there are no contraindications, continuing the weaning process as ordered would be the most appropriate action.
Choice B rationale
Decreasing the tidal volume is not necessarily the most appropriate action based on the client’s status. Tidal volume is the amount of air that is inhaled or exhaled during normal breathing.
While adjustments to tidal volume may be necessary in some cases, such as if the client is experiencing discomfort or if there are concerns about lung injury, there is no information in the scenario to suggest that a decrease in tidal volume is required at this time.
Choice C rationale
Switching the ventilator to pressure control is not necessarily the most appropriate action based on the client’s status. Pressure control ventilation is a mode of ventilation that can be used in certain situations, such as when there is a need to limit airway pressures. However, there is no information in the scenario to suggest that this change is required at this time.
Choice D rationale

Increasing the fractional concentration of inspired oxygen is not necessarily the most appropriate action based on the client’s status. The fraction of inspired oxygen (FiO2) is the concentration of oxygen in the gas mixture that the client is breathing. While adjustments to FiO2 may be necessary in some cases, such as if the client’s oxygen levels are low, there is no information in the scenario to suggest that an increase in FiO2 is required at this time.
Choice E rationale
Increasing the respiratory rate is not necessarily the most appropriate action based on the client’s status. The respiratory rate is the number of breaths that the client takes per minute, and it can be adjusted on the ventilator to meet the client’s needs. However, there is no information in the scenario to suggest that an increase in the respiratory rate is required at this time.
Choice F rationale
Changing the ventilator settings to continuous positive airway pressure (CPAP) is not necessarily the most appropriate action based on the client’s status. CPAP is a mode of ventilation that can be used in certain situations, such as during the weaning process. However, there is no information in the scenario to suggest that this change is required at this time.
Choice G rationale
Alerting the provider of the blood gas values is not necessarily the most appropriate action based on the client’s status. While it is important to communicate significant changes or concerns to the provider, there is no information in the scenario to suggest that the blood gas values are abnormal or require immediate attention.