A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing and urticaria after receiving an IV medication.
Which of the following actions should the nurse take first?

Choice A rationale

Initiating bleeding precautions is an important action when caring for a child with acute lymphocytic leukemia. These patients are at increased risk of bleeding due to decreased platelet counts.

Choice B rationale

Placing the child in a knee-chest position is not typically necessary in the care of a child with acute lymphocytic leukemia.

Choice C rationale

Applying viscous lidocaine to the oral mucosa is not typically necessary in the care of a child with acute lymphocytic leukemia.

Choice D rationale

Obtaining a rectal temperature every 4 hours is not typically necessary in the care of a child with acute lymphocytic leukemia. However, regular monitoring of the child’s temperature is important to detect any signs of infection.

Choice A rationale

Limiting a child’s fluid intake is not recommended for managing encopresis. Adequate hydration is important for preventing constipation, which is often associated with encopresis.

Choice B rationale

Increasing a child’s dairy intake is not typically recommended for managing encopresis. Some dairy products can contribute to constipation in some children.

Choice C rationale

Having a child sit on the toilet for 20 minutes at a time is not typically recommended. Prolonged sitting on the toilet can cause discomfort and create a negative association with bowel movements.

Choice D rationale

Having a child try to defecate 15 minutes after each meal is a common recommendation for managing encopresis. This takes advantage of the natural increase in colon activity following meals.