A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic?

A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.

B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.

C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.

D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.

The nurse should first administer the client's cefazolinto the client's IV access

Rationale:

Cefazolin is an antibiotic prescribed to treat the client's suspected infection indicated by the fever and hip surgical wound inflammation. Administering the antibiotic promptly is essential to initiate treatment and address the underlying cause of the fever. The prescription specifies administering cefazolin intravenously, so the nurse should prioritize administering it through the client's IV access. Administering acetaminophen or alprazolam may be appropriate based on the client's symptoms and vital signs, but addressing the infection with antibiotics takes precedence.