A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

A) Place the client close to the nurses' station:

While placing the client closer to the nurses' station may enhance supervision and monitoring, it does not address the immediate safety concern of preventing the client from removing the IV catheter again. This action may be considered after implementing measures to prevent further self-harm.

B) Cover the site with a stockinette dressing:

Covering the site with a dressing is important for maintaining a sterile environment around the IV site. However, if the client is disoriented and has already removed the IV catheter, simply covering the site may not prevent further attempts to remove it. Addressing the underlying issue of the client's behavior is necessary.

C) Administer a sedative:

Administering a sedative may be appropriate in certain situations to calm an agitated or disoriented client. However, it should not be the first action taken after observing the reinsertion of the IV catheter. Sedation should be used judiciously and only after other interventions to ensure the client's safety have been attempted.

D) Apply a soft mitten restraint:

This is the most appropriate action to prevent the client from removing the IV catheter again. A soft mitten restraint limits the client's ability to access the IV site while allowing some movement and comfort. It is a temporary measure to ensure the safety of the client and the integrity of the IV line until further assessment and interventions can be implemented.

A) Administer prescribed insulin:

Administering insulin is an essential aspect of managing type 1 diabetes mellitus, but before administering insulin, it's crucial to assess the client's current blood glucose level to determine the appropriate insulin dosage. Administering insulin without knowing the client's blood glucose level could lead to hypoglycemia if the blood glucose level is already low.

B) Check the calibration of the glucometer:

While it's important to ensure that the glucometer is calibrated correctly for accurate blood glucose readings, this step can be performed after obtaining the client's blood glucose level. Checking the calibration of the glucometer does not directly address the immediate need to assess the client's blood glucose level.

C) Obtain the client's capillary blood glucose level:

This is the most appropriate action to take first when providing morning care to a client with type 1 diabetes mellitus. Assessing the client's blood glucose level allows the nurse to determine the client's current glycemic status and make informed decisions about subsequent care, including insulin administration and breakfast provision.

D) Provide the client's breakfast:

Providing breakfast is an important aspect of morning care for a client with diabetes, but it should be done after assessing the client's blood glucose level. Depending on the client's blood glucose level, the nurse may need to adjust the timing or composition of the breakfast to ensure optimal glycemic control.