Question

A nurse on a pediatric unit is caring for a school-age child.

Exhibit 1
Nurses' Notes
0830:Child is alert and responsive to stimuli. Skin is warm and dry. Capillary refill less than 3 seconds. Respirations regular and shallow. Mild intercostal retractions noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. Abdomen is soft, flat, and non-distended.1100:Child appears restless. Moderate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally.​
Exhibit 2
Vital Signs
0830:
Temperature 37.1° C (98.8° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 90/60 mm HgPulse oximetry 97% on 2 L of oxygen via nasal cannula 1100:
Temperature 37.1° C (98.8° F) Heart rate 110/min Respiratory rate 30/min Pulse oximetry 94% on 2 L of oxygen via nasal cannula
Exhibit 3
Diagnostic Results
1200:CBC:Hemoglobin 10 g/dL (10 to 15.5 g/dL)Hematocrit 32% (32% to 44%)WBC count 11,000/mm3 (5,000 to 10,000/mm3)Arterial Blood Gases (ABGs):pH 7.49
What findings are consistent with the child's condition?
A) Restlessness, decreased heart rate, increased respiratory rate, increased oxygen saturation
B) Mild intercostal retractions, expiratory wheezes, increased heart rate, decreased oxygen saturation
C) Increased heart rate, increased capillary refill time, decreased respiratory rate, increased blood pressure
D) Regular heart rate, shallow respirations, increased capillary refill time, decreased hemoglobin levels

Answer 1

The findings consistent with the child's condition are mild intercostal retractions, expiratory wheezes, increased heart rate, and decreased oxygen saturation. These suggest respiratory distress, possibly due to a respiratory illness such as asthma or pneumonia.

Step-by-step explanation:

The findings consistent with the child's condition are mild intercostal retractions, expiratory wheezes, increased heart rate, and decreased oxygen saturation. These findings suggest that the child may be experiencing respiratory distress, possibly due to a respiratory illness such as asthma or pneumonia. The intercostal retractions indicate that the child is working harder to breathe, while the wheezes suggest narrowed airways. The increased heart rate and decreased oxygen saturation may be a response to the decreased oxygen levels in the blood.