The nurse knows that an 11-year-old child is in acute respiratory distress. The assessment may include all of the following except:
1. Clubbed nailbeds.
2. Pallor.
3. Rales and retractions.
4. Nasal flaring.
1
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1. Clubbing happens in chronic respiratory situations, not acute situations.
2. The child may become pale because of the lack of oxygen within the blood stream.
3. The rales are an indication of fluid within the lungs, and the retractions occur because the body is requiring more use of accessory muscles to breath.
4. Nasal flaring may occur to open airways larger to help obtain oxygen and blow off carbon dioxide.
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