Which initial assessment made by the triage nurse would suggest that a child requires immediate intervention?
a. The child has thick yellow rhinorrhea.
b. The child has a frequent nonproductive cough.
c. The child's oxygen saturation is 95% by pulse oximeter.
d. The child is grunting.
D
One of the initial observations for triage is respiratory rate and effort. Grunting is a sign of hypoxemia and represents the body's attempt to improve oxygenation by generating positive end-expiratory pressure. Nasal discharge would indicate that the child has a respiratory condition but does not mean the child needs immediate attention. A productive cough is not a finding that would indicate the child requires immediate attention. An oxygen saturation of 95% is a normal finding.
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