A nurse is caring for a school-age child who is 2 hr postoperative following cardiac catheterization.

The nurse observes blood on the child’s dressing.

Which of the following actions should the nurse take?

The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.

The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.

Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.

The correct answer is choice B. Instruct the client to notify the provider if diarrhea develops.

Choice A rationale:

Infusing the medication over 10 minutes is incorrect because penicillin G should typically be infused over 15-30 minutes to ensure proper administration and reduce the risk of adverse reactions.

Choice B rationale:

Instructing the client to notify the provider if diarrhea develops is correct because diarrhea can be a sign of a serious side effect, such as antibiotic-associated colitis, which requires prompt medical attention.

Choice C rationale:

Refrigerating the medication after reconstitution is not necessary for penicillin G. This instruction is more relevant for other medications that require refrigeration to maintain stability.

Choice D rationale:

Checking the client for a sulfa allergy is not relevant to penicillin G, as it is not a sulfa drug. This action would be more appropriate for medications containing sulfonamides.