A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

A. Wearing a mask is a measure of primary prevention rather than secondary prevention. It aims to prevent the transmission of the virus to others if the child is infected. However, in the context of secondary prevention, the focus is on early detection and management of the illness in the child to prevent complications.

B. This is a crucial instruction for tertiary prevention. Difficulty breathing can indicate severe illness, potentially requiring urgent medical intervention. Prompt recognition and treatment can prevent progression to respiratory failure, a serious complication of COVID-19.
C. Immunization is a form of primary prevention aimed at preventing infection before it occurs. As of now, COVID-19 vaccines are recommended for eligible school-age children to prevent infection and reduce transmission but do not directly address the management of suspected infection in a symptomatic child.
D. This is a critical step in secondary prevention. Testing for SARS-CoV-2 infection is necessary to confirm the diagnosis and initiate appropriate management and isolation measures if the child is positive. Early testing helps identify cases early and prevent further transmission in the school and community.

Blood pressure 86/46 mm Hg

A blood pressure of 86/46 mm Hg indicates hypotension. Hypotension can be a sign of inadequate perfusion and may lead to organ dysfunction if not promptly addressed. Immediate action may include reassessment of the client's hemodynamic status, fluid resuscitation if indicated, and consideration of vasopressor medications under provider orders.

Oxygen saturation 94% on 2 L via nasal cannula

Although the oxygen saturation of 94% is within the acceptable range (typically ≥ 92% for most clients),

it should be monitored closely as per the prescribed titration to maintain ≥ 92%. If the oxygen saturation drops below the target range, the nurse may need to adjust the oxygen flow rate or consider alternative oxygen delivery methods to ensure adequate oxygenation.

Prescription for the transfusion of 2 units of packed RBCs

Transfusion of packed red blood cells (RBCs) is indicated, suggesting the client may have significant anemia or ongoing bleeding requiring correction of hemoglobin levels. Immediate action involves verifying the blood product compatibility, initiating transfusion per protocol (including pre-transfusion assessments), and monitoring the client closely for any signs of transfusion reaction or complications during the transfusion.

Pulse rate 100/min, respiratory rate 28/min

Elevated pulse rate (tachycardia) and respiratory rate (tachypnea) can indicate physiological stress, inadequate oxygenation, or compensation for decreased cardiac output due to hypotension. These vital signs should be closely monitored for any worsening trends or signs of instability that may require immediate intervention, such as further assessment for hypovolemia or respiratory distress.