A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing and urticaria after receiving an IV medication.
Which of the following actions should the nurse take first?

Choice A rationale

Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.

Choice B rationale

Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.

Choice C rationale

Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.

Choice D rationale

Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.

Choice A rationale

Limiting a child’s fluid intake is not recommended for managing encopresis. Adequate hydration is important for preventing constipation, which is often associated with encopresis.

Choice B rationale

Increasing a child’s dairy intake is not typically recommended for managing encopresis. Some dairy products can contribute to constipation in some children.

Choice C rationale

Having a child sit on the toilet for 20 minutes at a time is not typically recommended. Prolonged sitting on the toilet can cause discomfort and create a negative association with bowel movements.

Choice D rationale

Having a child try to defecate 15 minutes after each meal is a common recommendation for managing encopresis. This takes advantage of the natural increase in colon activity following meals.