A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.

B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.

C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.

D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.

a. Administer the medication and alert the charge nurse: This choice suggests proceeding with medication administration but also informing the charge nurse. While it's important to communicate with the charge nurse regarding medication administration, in this scenario, there is no indication to hold the medication as the infant's heart rate is within the normal range. Therefore, alerting the charge nurse may not be necessary at this point.

b. Hold the medication and document cardiac assessment: This choice suggests holding the medication and documenting the cardiac assessment. However, since the infant's heart rate is within the normal range for their age, there is no clinical indication to hold the medication. Holding the medication unnecessarily could delay treatment and potentially lead to adverse outcomes if the medication is needed.

c. Administer the medication and document the heart rate.

Since the infant's heart rate of 120 beats per minute falls within the normal range for a 2-month-old, there is no indication to hold the medication. Administering the digoxin as prescribed and documenting the heart rate before administration are appropriate actions. It's important to ensure accurate documentation to track the infant's response to the medication and monitor for any changes in heart rate.

d. Hold the medication and recheck the heart rate in 1 hour: This choice suggests holding the medication and rechecking the heart rate in 1 hour. Again, since the infant's heart rate is within the normal range, there is no clinical indication to hold the medication or delay treatment. Rechecking the heart rate in 1 hour would be unnecessary and could potentially delay necessary medication administration.