The nurse assigns an unlicensed assistive personnel (UAP) to a client who has been placed on droplet precautions for a respiratory infection. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Rationale:
A. Consider having the teen's caregiver wait in the clinic reception area: Adolescents with ASD may experience heightened anxiety in unfamiliar environments. Having their caregiver nearby can offer a sense of security and comfort, making the experience less overwhelming.

B. Encourage the adolescent to handle the physical exam instruments: Allowing the adolescent to touch and explore the equipment before use helps reduce sensory-related anxiety. It also increases cooperation by promoting a sense of predictability and control.

C. Allow time for talking before beginning the physical assessment: Taking time to communicate and build rapport before initiating the assessment helps reduce anxiety and fosters trust. Many adolescents with ASD need more time to process information and adjust to new interactions.

D. Familiarize the adolescent with the clinic setting and healthcare staff: Gradual exposure to the physical space and people helps reduce sensory overload and builds comfort with the environment. Structured familiarity can prevent overstimulation and improve cooperation.

E. Make every effort to establish eye contact with the adolescent: Insisting on eye contact can increase distress, as many individuals with ASD find direct eye contact uncomfortable or overwhelming. Respecting their communication style is more effective than imposing neurotypical expectations.

Rationale:

• Place client on 2 L/minute oxygen: The client's oxygen saturation is borderline at 94%, and with suspected aortic aneurysm and possible compromise, low-flow oxygen can help ensure adequate tissue oxygenation. This intervention is safe and aligns with the standing PRN order.
• Start 0.9% sodium chloride fluid bolus: Given the client’s low-normal blood pressure and risk for aneurysm rupture, fluid resuscitation may be needed to support perfusion. Carefully titrated fluids are appropriate to maintain hemodynamic stability while awaiting definitive surgical management.
• Ensure surgical consent has been completed: Time is critical in suspected abdominal aortic aneurysm (AAA) rupture. Preoperative preparation, including confirming surgical consent, should be done early in anticipation of emergent vascular intervention.
• Insert indwelling urinary catheter: This is contraindicated until the aneurysm is surgically managed or ruled out. Inserting a catheter increases intra-abdominal pressure and may worsen an unstable aneurysm. Additionally, unnecessary movement may elevate the risk of rupture in a fragile vessel.
• Document any skin lesions on lower legs: Peripheral vascular disease is often comorbid with aneurysms. Noting skin lesions helps establish a vascular baseline and may inform intraoperative risk or postoperative wound healing considerations.
• Mark pedal pulse sites with a single use marker: Pulse marking is essential preoperatively in vascular cases to monitor distal perfusion post-surgery. Marking now ensures pulses can be quickly located after potential surgical repair of the aneurysm.