A preschooler presents to the emergency department with a history of vomiting, diarrhea, and fever..

A preschooler presents to the emergency department with a
history of vomiting, diarrhea, and fever over the past few days. She is
receiving 100% oxygen via non-rebreather mask. Vital signs are temperature
104.5°F, pulse 144 bpm, respiratory rate 22 breaths per minute, and BP 70/50 mm
Hg. She is listless and difficult to arouse and has weak peripheral pulses and
prolonged capillary refill. What nursing intervention takes priority?

a. Administering acetaminophen rectally for the high

fever

b. Administering IV antibiotics for the infection

c. Preparing the child for tracheal intubation

d.

A preschooler presents to the emergency department with a
history of vomiting, diarrhea, and fever over the past few days. She is
receiving 100% oxygen via non-rebreather mask. Vital signs are temperature
104.5°F, pulse 144 bpm, respiratory rate 22 breaths per minute, and BP 70/50 mm
Hg. She is listless and difficult to arouse and has weak peripheral pulses and
prolonged capillary refill. What nursing intervention takes priority?

a. Administering acetaminophen rectally for the high

fever

b. Administering IV antibiotics for the infection

c. Preparing the child for tracheal intubation

d. Giving an IV bolus of normal saline 20 mL/kg