A nurse is using the CUPS method of assessing a child's respiratory status and documents the following: open airway containing secretions, increased respiratory rate and effort, wheezing, mucous membranes pale pink in color, and fever
Based on this system, which is the appropriate rating for this child?
A.
Critical
B.
Potentially unstable
C.
Stable
D.
Unstable
ANS: D
According to this scale, the child has four determinants of unstable status (increased breathing rate, increased breathing effort, wheezing, and pale pink mucous membranes). An open airway with secretions and presence of fever both characterize the potentially unstable category. The nurse would classify this child as unstable.
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