A father brings his preschool aged child to the clinic because of a sore throat for the past two days and currently has a temperature of 103° F (39.4°C). The child is pale around the mouth and has flushed cheeks. The nurse processes a positive rapid strep test as prescribed. Which information should the nurse provide to the child's parent? Select all that apply.

Rationale:

• pH 7.40: A pH of 7.40 indicates that the client's acid-base balance is normal. This supports ventilation as the client’s respiratory system is effectively managing gas exchange.
• Blood pressure 112/77 mm Hg: This stable blood pressure is a sign that the client is adequately perfused, indicating management of hypovolemia. The blood pressure is now within a normal range, suggesting effective fluid resuscitation.
• PaCO2 42 mm Hg: The PaCO2 of 42 mm Hg is within normal limits, showing that the client's ventilation is adequate and confirming support of ventilation.
• Surgical dressing dry and intact: The intact dressing is important for preventing infection, as it ensures that there is no leakage or exposure to bacteria at the surgical site.
• Temperature 98.1° F (36.7° C): A temperature of 98.1° F (36.7° C is a normal and suggests successful rewarming or maintenance of normothermia, which contributes to Prevent infection as hypothermia can impair immune function and increase infection risk.
• Capillary refill 2 seconds: Capillary refill of 2 seconds is within normal limits and indicates good circulation and tissue perfusion, which is part of managing hypovolemia.
• Pain 0 on a scale of 0 to 10: The client’s report of no pain (pain score of 0) indicates that the goal of controlling pain and anxiety is being met, ensuring that the client is comfortable and stable.

A. Loperamide: Although it treats diarrhea, loperamide would worsen ammonia buildup by reducing bowel transit time. It doesn’t address the underlying hepatic encephalopathy causing confusion in cirrhosis.

B. Furosemide: This loop diuretic is used to manage ascites or edema, not elevated ammonia. It doesn’t treat the neurological symptoms caused by hepatic encephalopathy or improve stool-based ammonia excretion.

C. Lactulose: Lactulose lowers serum ammonia by trapping it in the colon and promoting its excretion through diarrhea. It directly treats confusion related to hepatic encephalopathy, making it the most important intervention here.

D. Intravenous (IV) human albumin: Albumin helps restore oncotic pressure in cases of ascites or low serum protein but does not affect ammonia levels or mental status. It supports fluid balance, not toxin elimination.