The nurse is reviewing the history and physical notes, as well as the nurse’s notes and laboratory results for a child.
The child is developmentally appropriate, interacting with his parents, and is in the percentile for weight and height.
The child’s lung sounds are clear and equal, a murmur is noted upon auscultation, and clubbing of the fingers is observed.
There is no skin breakdown, and the mucous membranes are pink and moist.
What condition is the child most likely experiencing, what two actions should the nurse take for this condition, and what two parameters should the nurse monitor to assess the child’s progress?

Choice A rationale

A lung biopsy is an invasive procedure that is typically performed to diagnose conditions such as lung cancer or interstitial lung disease. It is not the first-line test for evaluating increased shortness of breath in a client with COPD56.

Choice B rationale

Spirometry is a common, non-invasive test used to assess lung function and is particularly useful in conditions like COPD. It measures the volume and speed of air a person can inhale and exhale, which can help in assessing the severity of COPD56.

Choice C rationale

Antibody testing is typically used to diagnose conditions related to the immune system, such as allergies or autoimmune diseases. It is not typically used to evaluate shortness of breath in a client with COPD56.

Choice D rationale

A sweat test is used to diagnose cystic fibrosis by measuring the amount of salt in a person’s sweat. It is not used to evaluate shortness of breath in a client with COPD56.

• A. Set up supplemental oxygen delivery- This could be necessary as the client is being weaned off the ventilator and may require additional oxygen support.
• C. Gather supplies for extubation- As the client is being weaned off the ventilator and the pressure support has been decreased to 0 cm H2O, extubation may be imminent.
• E. Offer the client ice chips- Once extubated, the client may have a dry mouth and throat from the intubation tube. Ice chips can help soothe the throat and keep the mouth moist.

• B. Increase the fraction of inspired oxygen- This action is not indicated based on the information provided. The client’s oxygen saturation is within normal range and there’s no indication that the client is experiencing difficulty breathing or hypoxia.
• D. Place a nasogastric tube- There’s no indication in the scenario that the client has a need for a nasogastric tube. This procedure is typically done for clients who have difficulty swallowing or need help with feeding, neither of which is mentioned in the scenario.
• F. Suggest a different ventilator mode to the provider- The client is already being successfully weaned off the ventilator, as indicated by the decreasing pressure support. There’s no indication in the scenario that a different ventilator mode is needed.
• G. Set the ventilator to give mandatory breaths- This action would be counterproductive to the weaning process. The client is already on a ventilator mode with no mandatory breaths and is being successfully weaned off the ventilator.