[Solved]: A nurse on a pediatric unit is caring for a school-age…

A nurse on a pediatric unit is caring for a school-age child. Exhibit 1 Exhibit 2 Exhibit 3 Exhibit 4 Nurses’ Notes 0830: Child is alert and responsive to stimuli. Skin is warm and dry. Capillary refill less than 3 seconds. Respirations regular and shallow. Mild intercostal retractions noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. Abdomen is soft, flat, and non-distended. 1100: Child appears restless. Moderate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left mid-clavicular line 4 th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse