A 2-year-old child is admitted to pediatric unit with bronchiolitis. The nurse calls the physician fearing the child is going into respiratory failure based on which of the following assessment findings? Select all that apply

Question

A) Increased respiratory rate to 44 breaths/minute
B) Substernal retractions becoming more pronounced
C) New-onset expiratory grunting
D) Productive cough with white secretions
E) Faint wheezes noted in the posterior lung base

Answer 1

Ans: A, B, C
Feedback:
Children with impending respiratory failure due to airway or lung disease have rapid breathing; exaggerated use of the accessory muscles; retractions, which are more pronounced in the child than in the adult because of higher chest compliance; nasal flaring; and grunting during expiration.