A nurse is caring for a pediatric client receiving radiation therapy to the abdominal area. Which of the following statements by the nurse promotes proper skin integrity for the client?

• IV hydromorphone: This potent opioid analgesic is indicated for managing severe pain during vaso-occlusive crises in sickle cell disease, especially when pain reaches a level of 10/10 despite prior interventions. Rapid IV delivery ensures quicker pain relief.
• Pain: The child’s reported pain escalation from 7 to 10 out of 10, along with swelling and warmth of the knee, strongly indicates severe vaso-occlusive pain, which is a hallmark of sickle cell crisis requiring urgent analgesic management.

Rationale for Incorrect Choices:

• Oxygen at 2 L/min via nasal cannula: The child’s oxygen saturation remains normal at 96% on room air, indicating no current hypoxia. Supplemental oxygen is not necessary unless oxygen saturation drops or respiratory distress develops.
• Oral amoxicillin: There are no clinical signs or lab evidence of infection (e.g., normal WBC count, no fever), so antibiotics are not warranted. Prophylactic antibiotics may be used in certain sickle cell scenarios but are not indicated here.
• Hypoxia: The child maintains normal oxygenation, making hypoxia an unlikely contributing factor to the current presentation. Hypoxia would require both clinical signs (e.g., low SpO₂) and symptoms like shortness of breath.
• Signs of infection: The absence of fever, normal WBC count, and localized pain without erythema or drainage suggest that infection is not present at this time. Pain is due to vaso-occlusion, not infectious origin.

Rationale for Correct Answers:

• Apply pressure to the puncture site following the procedure: Applying pressure minimizes bleeding and helps close the puncture site, reducing the risk of cerebrospinal fluid leakage.
• Ensure the guardian has signed the consent form prior to the procedure: Invasive procedures require informed consent from a parent or guardian to meet legal and ethical standards.
• Monitor for paresthesia and tingling in extremities following the procedure: These could indicate nerve irritation or injury from the lumbar puncture, necessitating prompt evaluation.
• Ensure the child voids prior to the procedure: A full bladder can cause discomfort and interfere with positioning during the lumbar puncture.

Rationale for Incorrect Choices:

• Limit the child's fluid intake following the procedure: Fluids should be encouraged post-lumbar puncture to help reduce the risk of headache by promoting cerebrospinal fluid regeneration.
• Position the child in a prone position during the procedure: The proper position is lateral recumbent with knees drawn to the chest or sitting up with the back arched to open the lumbar space.
• Insert an indwelling urinary catheter during the procedure: Routine catheterization is unnecessary unless the child is unable to void or has another clinical indication.