A nurse is assessing a critically ill child's respiratory status. The child is grunting and has nasal flaring, but the pulse oximeter reads the child's oxygen saturation at 96%. Which nursing action is the priority in this situation?
A.
Conduct a thorough assessment and call the provider.
B.
Document the findings in the child's medical chart.
C.
Notify the rapid response team immediately.
D.
Turn up the oxygen and reassess the child in 30 minutes.
ANS: A
The oxygen saturation does not correlate with the child's work of breathing. The nurse should do a more complete assessment, including vital signs, and notify the provider. Documentation should be thorough, but the nurse needs to take further action. Depending on institutional policies, notifying the rapid response team may be appropriate if the child needs further attention and the primary provider is not available. This child is too ill to just turn up the oxygen and reassess later.
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