A nurse is preparing to perform endotracheal suctioning for a client. Which of the following actions should the nurse plan to take?

Rationale:

A. Testosterone gel is a topical hormonal medication that can be absorbed through the skin. The nurse must wear clean gloves during application to prevent accidental exposure and secondary hormonal effects such as virilization in females or children. Hand hygiene before and after application is also essential.

B. Clients are typically instructed to avoid washing the application site for several hours (often at least 2–6 hours depending on the product) to ensure adequate absorption. Waiting only 1 hour may be insufficient for proper medication uptake.

C. Serum testosterone levels are not typically reassessed within 1 week of starting therapy. Hormone levels and clinical response are usually evaluated after several weeks to months to determine effectiveness and adjust dosing.

D. Testosterone gel should not be applied to the genitals. It is typically applied to clean, dry, intact skin of the shoulders, upper arms, or abdomen depending on the product instructions. Application to the genital area increases irritation and inconsistent absorption.

Rationale:
A. While fever may contribute to discomfort, analgesics do not address the priority problem, which is impaired oxygenation evidenced by tachypnea and an oxygen saturation of 90%. The nurse should prioritize respiratory support and oxygen monitoring rather than comfort measures.

B. Infants with respiratory distress are often at risk for dehydration due to fever and increased respiratory rate. Oral intake should not be automatically limited unless there is a risk of aspiration or severe respiratory compromise. Hydration is generally encouraged, and in some cases, small frequent feeds or IV fluids may be needed.

C. Peak expiratory flow measurement requires patient cooperation and is typically used in older children or adults who can follow instructions. Infants are unable to perform this test reliably, making it inappropriate.

D. The infant has signs of respiratory distress (tachypnea, fever, thick secretions, and low oxygen saturation). Continuous oxygen saturation monitoring is essential. In infants, the great toe is an appropriate site for pulse oximetry, allowing accurate and continuous assessment of oxygenation status to guide further interventions such as oxygen therapy and airway suctioning.