The nurse is assessing a 6-year-old male client with a histo…
The nurse is assessing a 6-year-old male client with a history of asthma who was brought to the emergency department (ED) and reports shortness of breath during a soccer game. The nurse completes a triage assessment with the following data. Vitals Temperature 99.20 FHeart Rate 96Respirations 32Blood pressure 97/66Oxygen saturation 89% (on room air) Health History Born at 30 Weeks History of Asthma Multiple environmental allergies Allergic to penicillin Immunizations are current Physical/Psychosocial Assessment Findings Child reports no pain Child is restless and refuses to lie down in bed Wheezing in both lungs Minimal air movement noted in lower lobes bilaterally Child only nods head “yes” or “no” to questions Parents are at the bedside and providing comfort Parents deny that the child was exposed to any triggers Moderate intercostal retractions present Indicated if urgent follow up by the nurse is necessary (immediate follow up needed) or not necessary (no immediate follow up needed). 1. Temperature of 99.20F [option1] 2. Oxygen Saturation of 89% (on room air) [option2] 3. Allergy to penicillin [option3] 4. Wheezing in the lungs [option4] 5. Respirations of 32 [option5] 6. Parents deny the child was exposed to any triggers [option6]
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