The nurse is preparing to administer an ampicillin suspension labeled, "Ampicillin 250 mg/5 mL," to a child with impetigo. The prescription: is for 500 mg four times a day. How many mL should the child receive per day?

(Enter numeric value only.)

Potential Condition - Delirium:

The client exhibits confusion, difficulty with memory, and disorientation (e.g., not knowing what happened, asking about her husband, inability to recall medications), which are typical signs of delirium. Delirium is an acute change in mental status and is common in older adults post-surgery, particularly after trauma or hospitalization.

Actions to Take:

Reorient to environment: Reorientation helps to reduce confusion and anxiety. The client is unsure of her surroundings and what is happening, so gently reminding her of the situation can improve awareness and reduce distress.

Institute fall precautions: Delirium increases the risk of falls due to impaired cognitive function. Given that the client is ambulating with assistance and has difficulty understanding instructions (e.g., unsure of the call light), instituting fall precautions is essential to prevent injury.

Parameters to Monitor:

Nutritional intake/intake and output: The client had difficulty feeding herself and consumed only a small portion of the meal. Monitoring her nutritional intake is important for overall recovery and to prevent dehydration, particularly given her dry mucosa and skin tenting.

Intracranial pressure: Given the client's age, recent surgery, and possible trauma from the motor vehicle accident, monitoring intracranial pressure (via MRI order) is necessary to rule out any traumatic brain injury or worsening of symptoms, especially since she has periods of confusion and disorientation.

A. Advancing to clear liquids is important for nutritional support but is secondary to ensuring urinary function is restored.

B. Urinary retention is a concern after anesthesia, but it is not an immediate threat. This intervention is conditional (“if unable to void”), meaning it is implemented only if needed.

C. Postoperative clients are at high risk for infection. Cefazolin (a broad-spectrum antibiotic) is a prophylactic measure to reduce the risk of surgical site infection, which is a priority intervention immediately after surgery. This should be implemented first, since infection prevention begins as soon as the client arrives from PACU.

D. A CBC is important for monitoring but is not urgent in comparison to immediate care needs like urinary output.