6-year-old child.

Vomited 3 times in the past 24 hr. Irritable behavior for the past 24 hr. The respiratory infection started 3 days ago.

Brudzinski's and Kernig's signs are positive.

Vital Signs.

Respiratory rate 28/min.

Pulse rate 120/min.

BP 108/64 mm Hg. Pain level of 6 on a scale from 0 to 10. Medication Administration Record.

Vancomycin 300 mg IV q 6 hr following blood cultures.

Acetaminophen 240 mg PO q 6 hr PRN fever.

A nurse is planning care for a child during admission to the facility.

Which of the following actions should the nurse take first?

The correct answer isChoice C.

Choice A rationale:

Encouraging the client to drink low-protein supplements is not the best action. Protein is essential for tissue repair and healing, especially when the body is under stress, such as during radiation therapy. Therefore, it would be more beneficial to encourage high-protein foods and supplements.

Choice B rationale:

Serving the client’s largest meal in the evening is not the most effective strategy. Radiation therapy can cause nausea and vomiting, which are often worse later in the day. Therefore, it might be more beneficial to serve a larger meal earlier in the day when the client is more likely to tolerate it.

Choice C rationale:

Providing the client with cold foods rather than hot foods is the correct action. Hot foods can often exacerbate feelings of nausea, which are common side effects of radiation therapy.Cold foods are generally better tolerated.

Choice D rationale:

Telling the client to drink two glasses of water with meals is not the best advice. While hydration is important, drinking large amounts of fluid with meals can contribute to early satiety, which can further decrease the client’s food intake. It might be more beneficial to encourage the client to drink fluids between meals.

Choice A rationale:

Checking the medical record for prior blood glucose test results is a task that can be delegated to the assistive personnel (AP). It provides relevant information for the nurse to assess the client's current condition. However, it is not the most crucial step in ensuring the safe performance of the blood glucose test.

Choice B rationale:

Asking the client if she has taken her antidiabetic medication today is important, but this task is better suited for the nurse, as it requires accurate communication with the client about their medication history and adherence. Delegating this task to the AP may lead to potential misunderstandings or errors in the information provided.

Choice C rationale:

The nurse should determine if the AP has the necessary skills and competence to perform the blood glucose test. Delegating tasks based on the competency of the staff member ensures the safety and well-being of the client. If the AP is not skilled in performing the test, the nurse should assign the task to someone else or perform the test personally.

Choice D rationale:

The nurse should not directly perform the blood glucose test if it can be safely delegated to the AP. Delegating appropriate tasks to competent staff members allows nurses to focus on more complex aspects of client care and ensures efficient use of resources within the healthcare team.