A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing and urticaria after receiving an IV medication.
Which of the following actions should the nurse take first?

When prioritizing care for multiple clients, the nurse should first assess the client who is most unstable and has the most urgent needs. In this case, the adolescent with sickle cell anemia and slurred speech should be assessed first. Slurred speech could indicate a stroke, which is a life-threatening condition that requires immediate medical attention. The other clients, while they also require care, are not in immediate danger and can be assessed after the adolescent with sickle cell anemia.

The correct answer is choice a. Discourage the child from coughing.

Choice A rationale:

Discouraging the child from coughing is important because coughing can dislodge clots and cause bleeding at the surgical site, which is a common complication after a tonsillectomy.

Choice B rationale:

Providing cranberry juice to the child is not recommended because acidic juices can irritate the throat and cause discomfort or pain.

Choice C rationale:

Maintaining the child in a supine position is not ideal as it can increase the risk of aspiration. Instead, the child should be positioned on their side or with the head elevated to facilitate drainage and reduce the risk of aspiration.

Choice D rationale:

Administering an analgesic to the child on a scheduled basis is important for pain management, but it is not the most immediate action to take one hour postoperatively. Pain management should be part of the overall care plan.