The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery.
Which menu item(s) should the nurse request for this client? (Select all that apply).

Choice A rationale:

Checking the client's temperature is important for assessing the client's condition, but it is not a priority before administering penicillin G IV for meningitis.

Choice B rationale:

Assessing the client's level of consciousness is essential for monitoring neurological status, but it is not the highest priority action before administering penicillin G IV for meningitis.

Choice C rationale:

Asking the client about any history of allergies is important for assessing potential allergic reactions to medications. However, the most critical action before administering penicillin G IV for meningitis is to obtain a blood sample for culture and sensitivity. This action helps identify the causative organism and guides appropriate antibiotic therapy, as meningitis can be life-threatening and requires prompt treatment.

Choice D rationale:

Obtaining a blood sample for culture and sensitivity is the highest priority action before administering penicillin G IV for meningitis. Identifying the specific pathogen responsible for the infection is crucial for selecting the most effective antibiotic therapy and preventing complications.

Choice A rationale:

Beginning continuous observation for transient episodes of neurologic dysfunction is important in the assessment and monitoring of the client's condition. However, in this scenario, the client is presenting with symptoms suggestive of a possible stroke or cerebrovascular event, and time is crucial. The nurse should prioritize actions that can lead to prompt diagnosis and treatment.

Choice B rationale:

Starting two large bore intravenous (IV) catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the most urgent action. The client's symptoms, including sudden right-sided numbness, weakness, and facial droop, are indicative of a possible ischemic stroke. IV fibrinolytic therapy is time-sensitive and has a limited window of effectiveness. Establishing IV access and determining eligibility for this therapy should be the nurse's top priority to potentially improve the client's outcome.

Choice C rationale:

Administering aspirin to prevent further clot formation and platelet clumping is an important intervention in the treatment of ischemic stroke. However, it should not be the first action in this scenario. The priority is to assess for eligibility for IV fibrinolytic therapy, as this intervention has a more immediate impact on reversing the stroke's effects.

Choice D rationale:

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is a reasonable nursing intervention to prevent complications such as aspiration and promote optimal cerebral blood flow. However, it is not the most urgent action in this case. The priority should be on assessing and potentially treating the stroke with IV fibrinolytic therapy.