A nurse is preparing to administer ondansetron 0.15 mg/kg IV bolus every 4 hr. The client weighs 41 kg (92 lb). How many mg should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A. Determine the client's airway patency: Ensuring the airway is patent is the highest priority in the immediate postoperative period because airway compromise can be life-threatening. This assessment is performed first to address the most critical physiological need.

B. Evaluate the client's level of consciousness: After airway and basic respiratory assessment, the nurse evaluates the client’s level of consciousness to detect neurological changes, sedation effects from anesthesia, or potential complications.

C. Auscultate the client's lung sounds: Respiratory assessment, including auscultation, identifies complications such as atelectasis or pneumonia. While vital, it follows confirming airway patency to prioritize immediate safety.

D. Ask the client to rate their pain: Pain assessment is important for comfort and recovery but is performed after addressing airway, breathing, and neurological status. It is lower priority compared with immediate physiological needs.

A. Clear fluid drainage from the nares: Clear, watery drainage following facial trauma can indicate cerebrospinal fluid (CSF) leakage, which is a hallmark sign of a basilar skull fracture. The presence of CSF raises concern for a more serious intracranial injury and requires immediate reporting and further evaluation.

B. Report of pain around the eyes: Periorbital pain is common with nasal fractures and facial trauma but is not specific for a skull fracture. While it warrants assessment, it does not suggest intracranial involvement or CSF leakage.

C. Dried blood in the mouth: Blood in the mouth may result from oral or nasal trauma and is expected with nasal fractures. It does not indicate a skull fracture unless accompanied by other neurological or cerebrospinal signs.

D. Mandibular asymmetry: Misalignment of the jaw is consistent with a mandibular fracture rather than a skull fracture. While it may be present in facial trauma, it does not indicate intracranial injury or CSF leakage.