A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p>

The client is at risk for developing

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due to

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.

A. Incorrect. Obtaining capillary blood glucose level every 2 hr is appropriate for a client who has type 1 diabetes mellitus, but it does not address the ankle injury.

B. Incorrect. Checking the neurovascular status of the client's lower extremities every hour is important for a client who has an ankle injury, but it does not require clarification with the provider.

C. Correct. Applying a cold pack to the client's ankle for 30 min every hour can reduce swelling and inflammation, but it can also impair circulation and increase the risk of tissue damage in a client who has diabetes mellitus. Therefore, the nurse should clarify this prescription with the provider before implementing it.

D. Incorrect. Maintaining the affected ankle elevated and immobilized can help prevent further injury and promote healing, but it does not require clarification with the provider.

a. Administer the medication and alert the charge nurse: This choice suggests proceeding with medication administration but also informing the charge nurse. While it's important to communicate with the charge nurse regarding medication administration, in this scenario, there is no indication to hold the medication as the infant's heart rate is within the normal range. Therefore, alerting the charge nurse may not be necessary at this point.

b. Hold the medication and document cardiac assessment: This choice suggests holding the medication and documenting the cardiac assessment. However, since the infant's heart rate is within the normal range for their age, there is no clinical indication to hold the medication. Holding the medication unnecessarily could delay treatment and potentially lead to adverse outcomes if the medication is needed.

c. Administer the medication and document the heart rate.

Since the infant's heart rate of 120 beats per minute falls within the normal range for a 2-month-old, there is no indication to hold the medication. Administering the digoxin as prescribed and documenting the heart rate before administration are appropriate actions. It's important to ensure accurate documentation to track the infant's response to the medication and monitor for any changes in heart rate.

d. Hold the medication and recheck the heart rate in 1 hour: This choice suggests holding the medication and rechecking the heart rate in 1 hour. Again, since the infant's heart rate is within the normal range, there is no clinical indication to hold the medication or delay treatment. Rechecking the heart rate in 1 hour would be unnecessary and could potentially delay necessary medication administration.