Pediatric ATI Practice Exam

A toddler has ingested a toilet bowl cleaner and exhibits edematous lips and drooling. What should the nurse's priority action be?

1. Remove the child's contaminated clothing

2. Check the child's respiratory status

3. Administer an antidote to the child

4. Establish IV access for the child

The correct answer is: Check the child's respiratory status

The priority action in this scenario should focus on assessing the child's respiratory status due to the potential for airway compromise following ingestion of a caustic substance like toilet bowl cleaner. Edematous lips and drooling suggest a risk of swelling in the oral and pharyngeal areas, which can lead to airway obstruction or difficulty breathing. By checking the respiratory status first, the nurse can identify any immediate threats to the child’s airway and intervene accordingly. Establishing IV access, removing contaminated clothing, or administering an antidote may be important steps in the clinical management of the situation, but they come after ensuring that the child can breathe adequately. In emergencies involving potential poisoning with caustic substances, the airway takes precedence. It's crucial to assess breathing and airway patency before progressing with other interventions, thereby ensuring the child's safety and stability.