Which initial assessment made by the triage nurse suggests 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
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A Nasal discharge indicates that the child has a respiratory condition but does not
mean the child needs immediate attention.
B A productive cough is not a finding that indicates that the child requires
immediate attention.
C An oxygen saturation of 95% is a normal finding.
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.
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