A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

Choice A reason: Increasing oral fluids may help with hydration, but it will not reduce skin flushing caused by lisinopril. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that dilates blood vessels and lowers blood pressure. Flushing occurs due to increased blood flow to the skin.

Choice B reason: Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces chest pain caused by angina. It is not indicated for skin flushing caused by lisinopril. Moreover, nitroglycerin can lower blood pressure further and cause hypotension, headache, dizziness, and fainting.

Choice C reason: Going to an emergency department is not necessary for skin flushing caused by lisinopril. Flushing is not a sign of an allergic reaction or anaphylaxis, which would require immediate medical attention. Flushing is also not a symptom of a heart attack or stroke, which would present with other signs such as chest pain, shortness of breath, arm numbness, or slurred speech.

Choice D reason: Reassuring the client that facial flushing is a common side effect of lisinopril is the best action for the nurse to take. Flushing is not harmful or dangerous, and it usually subsides within a few hours. The nurse should explain the mechanism of action of lisinopril and its benefits for lowering blood pressure and preventing angina. The nurse should also advise the client to monitor his blood pressure regularly and report any signs of hypotension, such as dizziness, lightheadedness, or fainting.

Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.

Choice B reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.

Choice C reason: This is the correct answer because keeping chest tube container below the site of insertion is the most important action for the nurse to take. Chest tube container is a device that collects air or fluid from the chest tube and maintains negative pressure in the pleural space or mediastinum. Keeping chest tube container below the site of insertion can prevent backflow of air or fluid into the chest cavity and maintain adequate drainage. If the chest tube container is raised above the site of insertion, it can cause tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and heart.

Choice D reason: Administering PRN pain medication prior to transport is not a timely action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.