Monitoring For Complications And Clinical Deterioration Practice Test

A 4-year-old child with a history of asthma is in the emergency department for respiratory distress after a viral illness. Current status: anxious, speaking in 1–2 word phrases; vital signs: heart rate 156/min, respiratory rate 44/min, temperature 38.1°C (100.6°F), oxygen saturation 89% on room air; breath sounds: diffuse wheezing that becomes markedly diminished in the bases; retractions are present. Which assessment finding indicates the child is deteriorating?

A 78-year-old client with multiple comorbidities (chronic kidney disease, hypertension, and chronic anemia) is admitted for cellulitis and is receiving intravenous antibiotics. Current status: new onset confusion and cool, mottled skin. Vital signs: temperature 36.1°C (97.0°F), heart rate 112/min, blood pressure 88/46 mm Hg, respiratory rate 24/min, oxygen saturation 93% on room air. Labs: white blood cell count 3,200/mm³ (low), lactate 4.1 mmol/L (high). The nurse should REPORT which finding to the healthcare provider FIRST?