A nurse is caring for an adolescent who has been admitted to the PICU with a diagnosis of septic shock. The nurse notes the following :

Exhibits

When planning care for this client, the nurse should anticipate a provider's prescription for which of the following?

Choice A reason: This is a finding that the nurse should report to the provider. A pressure dressing is applied to the site of the catheter insertion to prevent bleeding and hematoma formation. If the dressing is saturated with bloody drainage, it indicates that the bleeding is not controlled and may lead to hemorrhage or infection.

Choice B reason: This is a finding that the nurse should report to the provider. Pulses of the extremity where the catheter was inserted should be equal to or stronger than the other extremity. If the pulses are diminished, it indicates that there is impaired blood flow to the extremity, which may be caused by arterial occlusion, thrombosis, or vasospasm.

Choice C reason: This is a finding that the nurse should report to the provider. The color and temperature of the extremity where the catheter was inserted should be similar to the other extremity. If the extremity is cool and pale, it indicates that there is inadequate perfusion to the extremity, which may be caused by the same factors as the diminished pulses.

Choice D reason: This is a finding that the nurse should report to the provider. Pain is an indicator of tissue damage or inflammation. The adolescent should have minimal or no pain after the procedure, as the site is numbed with local anesthesia. If the pain is present or increases, it indicates that there is a complication, such as bleeding, infection, or nerve injury.

Choice E reason: This is not a finding that the nurse should report to the provider. The apical pulse is the heart rate measured at the apex of the heart. It is a routine vital sign that the nurse should monitor after the procedure, but it is not a sign of a complication unless it is abnormal, such as too fast, too slow, or irregular. The nurse should compare the apical pulse with the baseline and the expected range for the adolescent's age and condition.

Choice A: The reason why the child is taking the medication

It is essential for the nurse to explain why the child is taking the medication. This helps the parents or caregivers understand the importance of the medication and ensures they are more likely to adhere to the prescribed treatment plan. Knowing the reason for the medication can also help in recognizing the signs of improvement or any potential issues that may arise during the course of treatment.

Choice B: The adverse effects of the medication

Informing the parents or caregivers about the potential adverse effects of the medication is crucial. This knowledge allows them to monitor the child for any side effects and seek medical attention if necessary. It also helps in managing expectations and reduces anxiety if any common side effects occur.

Choice C: Stopping the medication when the child feels better

This is not a correct choice. It is important to complete the full course of antibiotics as prescribed, even if the child starts feeling better. Stopping the medication prematurely can lead to incomplete treatment of the infection and may contribute to antibiotic resistance.

Choice D: Written information about the medication

Providing written information about the medication is important as it serves as a reference for the parents or caregivers. This information can include dosage instructions, potential side effects, and any other relevant details. Written instructions help ensure that the medication is administered correctly and consistently.

Choice E: Using a kitchen spoon to administer the medication

This is not a correct choice. Using a kitchen spoon to administer medication is not recommended as it can lead to inaccurate dosing. It is important to use a proper measuring device, such as an oral syringe or a medication cup, to ensure the correct dosage is given.