A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Choice A reason: Hypernatremia is unlikely with 0.45% sodium chloride, a hypotonic solution that dilutes serum sodium. Over-infusion risks hyponatremia, not high sodium levels. Monitoring for hypernatremia is inappropriate, as the solution’s low sodium content does not contribute to elevated sodium in fluid therapy.
Choice B reason: Assessing for fluid overload is essential, as 0.45% sodium chloride, being hypotonic, can cause water to shift into cells, risking pulmonary or cerebral edema. This is critical in clients with renal or cardiac issues, where monitoring for dyspnea or swelling ensures safe fluid administration.
Choice C reason: Hypoglycemia is not directly linked to 0.45% sodium chloride, which affects fluid and electrolytes, not glucose. Fluid shifts may indirectly stress metabolism, but hypoglycemia relates to fasting or insulin issues, making this an inappropriate focus for monitoring in this fluid therapy context.
Choice D reason: Dehydration is unlikely, as 0.45% sodium chloride provides free water, promoting hydration. It corrects hypernatremia or replaces fluid losses. Evaluating for dehydration is unnecessary unless infusion is inadequate or losses persist, which is not indicated in the context of this hypotonic solution.

Choice A reason: Instructing pregnant visitors to stay 3 feet away is insufficient, as radiation from a sealed implant requires greater distance (typically 6 feet) or complete avoidance. Pregnant individuals should not visit to minimize fetal exposure, making this precaution inadequate and incorrect for safety.
Choice B reason: Wearing a lead apron shields the nurse from radiation exposure during close contact with the sealed implant, adhering to ALARA (As Low As Reasonably Achievable) principles. This protects the nurse while providing care, making it a necessary and correct safety measure.
Choice C reason: Placing the client in a semi-private room is unsafe, as radiation from the implant could expose other patients. A private room is required to minimize radiation risk to others, making this action incorrect and against radiation safety protocols.
Choice D reason: Closing the client’s door reduces radiation exposure to others outside the room, as sealed implants emit continuous radiation. This containment measure, combined with signage, ensures safety for staff and visitors, making it a correct and essential action.
Choice E reason: Limiting visitors to 30 minutes per day minimizes cumulative radiation exposure, protecting visitors from the sealed implant’s emissions. Time restrictions are standard in radiation safety protocols, ensuring minimal risk while allowing controlled visits, making this a correct action.