A 3-year-old child presents in the pediatric emergency room and is very lethargic. The mother found her in the medication cabinet at home but is unsure what she ingested. What is the nurse’s first priority?

Choice A reason: Obtaining a detailed history is important to identify the ingested substance, but it is not the first priority in a lethargic child. Lethargy may indicate compromised airway, breathing, or circulation, which are life-threatening. Addressing immediate physiological stability takes precedence over history collection in an emergency setting. Choice B reason: Obtaining vital signs and assessing perfusion is critical in evaluating a child with potential poisoning, but it is secondary to ensuring airway and breathing stability. Lethargy may signal respiratory depression or hypoxia, which require immediate assessment to prevent further deterioration before vital signs are fully evaluated. Choice C reason: Assessing the child’s airway and breathing is the first priority in a lethargic child with suspected ingestion. Lethargy may indicate central nervous system depression or hypoxia, which can compromise airway patency and respiratory function. Immediate assessment ensures life-threatening conditions are addressed first, following the ABCs (airway, breathing, circulation) of emergency care. Choice D reason: Administering activated charcoal may be appropriate to prevent absorption of certain toxins, but it is not the first priority. Without ensuring airway and breathing stability, charcoal administration could be unsafe, especially if the child is lethargic and at risk for aspiration, making this a secondary intervention.