The registered nurse is performing triage at a pediatric emergency department. Which client should be seen first?

Question

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The client with abdominal pain has abnormal vital signs, which is a sign of a systemic condition. Adult criteria apply to adolescent clients in terms of physiological signs/symptoms. A pulse of 120/min signals dehydration and this client's respirations are above normal. This is the most serious acuity. (Option A) The client with a history of CF would be treated second as clients with CF have chronic respiratory issues related to the thick mucus plugging the airways. This client will probably need antibiotics but is stable and can wait. The severity of the situation is considered when prioritizing client care based on airway, breathing, and circulation (ABC). The seriousness of the adolescent client's condition related to "C" (dehydration) is a priority over a relatively stable "B." There is nothing indicating that this client is in respiratory distress. (Option B) The infant has diaper dermatitis from irritation of urine and stool on the skin. A secondary infection with Candida albicans can occur. Diaper dermatitis is most common in infants age 9-12 months. Ointment will be provided. Mild diaper dermatitis is treated with a topical water-impermeable barrier (eg, zinc oxide). If the infant has an infection with Candida albicans, an antifungal topical medication is also used. When care must be prioritized, young children do not automatically go first. Prioritization is decided by the client's acuity. (Option C) The grade-school client has a limited extremity injury and the priority principle is always "life before limb." Therefore, the client with abdominal pain is more important. Educational objective: In prioritization, the severity of ABC is more important than absolute order. As a result, a severe "C" client comes before a stable "B" client. The priority principle is to take "life before limb" in this order. When care must be prioritized, young children do not automatically go first.

The Registered Nurse Is Performing Triage at a Pediatric Emergency