Difficulty: Medium
Average Score: 85%
Full-length
At 0800 hours the nurse assesses the 3-year-old with rubeola and finds that the child is restless, hard to calm, feverish, reporting pain, is tachycardic, and has crackles and rhonchi in the lung bases. The nurse compares the 0800-hour VS to the previously obtained VS (See VS chart). Acetaminophen was last given at 0600 hours. What should be the nurse's priority?
Correct answer
C
Rationale
Crackles and rhonchi suggest possible pneumonia, a serious complication of rubeola. Notifying the HCP is critical for timely intervention.