A nurse is caring for an 8-year-old with Guillain-Barré Syndrome (GBS).On hourly rounds,the nurse assesses that the child's lung sounds are diminished,respiratory rate is 8 breaths/min and shallow,and pulse oximeter is 88%.What action by the nurse takes priority?
A) Administer high-flow oxygen by mask.
B) Call the rapid response team; prepare for intubation.
C) Encourage the patient to take slow, deep breaths.
D) Have the patient use the incentive spirometer.

Question

Quizplus · Accepted Answer

In GBS,respiratory muscles can be affected,leading to respiratory failure.The nurse needs to prepare for intubation.The child's muscles are too weak for oxygen or the spirometer to help her,and she may be too weak to use the spirometer or to take deep breaths.

A Nurse Is Caring for an 8-Year-Old with Guillain-Barré Syndrome