A nurse is caring for a school-age child following a femoral venous cardiac catheterization. Which of the following actions should the nurse take?

Initiating airborne precautions. The child’s symptoms (fever, headache, nausea, lethargy, irritability, nuchal rigidity, and elevated WBC count) suggest bacterial or viral meningitis, which requires airborne precautions if tuberculosis or certain viral causes are suspected.

WBC. The child's WBC count is elevated (14,000 mm³), indicating a possible infection, which supports the need for precautions to prevent transmission.

Administering potassium chloride. The child's potassium level (3.8 mEq/L) is within the normal range (3.4-4.7 mEq/L), so potassium replacement is unnecessary.

Pain level. While pain management is important, it does not directly relate to the need for airborne precautions.

Administering acyclovir. Acyclovir is an antiviral used to treat herpes infections, but there is no indication in the scenario that the child has a viral infection requiring acyclovir.

Lymph node findings. While cervical lymphadenopathy can occur with infections, it does not necessarily indicate the need for acyclovir.

Increasing environmental stimuli. The child is already lethargic and irritable, so reducing stimuli (not increasing) would be more appropriate.

Potassium level. The potassium level is normal and does not indicate a need for intervention.

A. "Ask her if she is ready to eat her sandwich for lunch." Asking if the child is ready to eat might increase resistance, as toddlers often assert their autonomy by saying "no." This does not provide an option that would allow the toddler to make a choice.

B. "Ask her if she would like to have her favorite sandwich for lunch." This is a yes/no question which might lead to refusal, especially if the child is already in a stage of negativism, where they are more likely to resist being told what to do.

C. "Tell her that she may have a sandwich or soup for lunch." Offering choices between two acceptable options gives the toddler a sense of control, which can help reduce oppositional behavior. This approach aligns with the developmental stage of toddlers who are asserting independence.

D. "Tell her she is having her favorite sandwich for lunch." Telling the child what they will have to eat might lead to resistance. Providing a choice rather than making a statement gives the child more agency in their decision-making.