The child’s assessment upon arrival to the ED is as follows:Pulse: 60 beats per
The child’s assessment upon arrival to the ED is as follows:Pulse: 60 beats per minute (bpm)Temperature: 98.9 °FRespirations: 16 breaths per minute and irregularBlood pressure: 75/45 mmHgPulse oximetry: 99% on 5 L oxygen via nasal cannulaGlucose: 272 mg/dLPhysical AssessmentLethargic and unresponsiveDusky in appearanceCapillary refill: 4 secondsExtremity pulses: +2 and cool to touchAbdomen: round, soft and nondistended and pain is not noted upon palpationPast medical history: unremarkablePer grandmother, the child came to their house for a visit 2 days ago and has been fine until he was found lying on the floor. Which of the following immediate actions should the nurse take and why? Select all that apply.Administer a fluid bolus as ordered.Draw blood for an arterial blood gas and basic metabolic panel.Turn oxygen down to 2 liters.Administer inotropic support with dobutamine.Assess vaccination history.Prepare to intubate the child. Rationale for choices: Health Science Science Nursing NUR 4257 Share EmailCopy link Comments (0)
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