A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Explanation

A. Administer the medication to the toddler each evening.

Montelukast is a long-term control medication used for the management of asthma in both children and adults. It is typically taken once daily in the evening to provide continuous asthma control. Consistency in taking the medication is important to maintain its effectiveness.

Providing an additional dose of the medication prior to physical activity in (option B) is not a standard recommendation for montelukast use. Montelukast is not a rescue medication and does not provide immediate relief for asthma symptoms triggered by physical activity. In such cases, a short-acting bronchodilator medication, such as albuterol, is commonly used prior to physical activity.

Mixing the medication in juice prior to administration in (option C) is not recommended unless specifically instructed by the healthcare provider or indicated in the medication instructions.

Montelukast is available in various formulations, including chewable tablets and granules, which can be taken directly or mixed with certain foods or liquids. However, the specific instructions should be followed as provided by the healthcare provider or medication label.

Administering the medication when the toddler in (option D) has an acute asthma attack is not the intended use of montelukast. Montelukast is a long-term control medication aimed at preventing asthma symptoms and maintaining asthma control over time. For acute asthma attacks, a short-acting bronchodilator medication is typically used.

Therefore, the nurse should instruct the parents to administer the medication to the toddler each evening (option A) as part of the routine, long-term management of asthma.

The client's symptoms of feeling dizzy, having a racing heart, and becoming pale while lying on their back are consistent with supine hypotension syndrome, also known as vena cava syndrome. This occurs when the weight of the uterus compresses the inferior vena cava, reducing blood flow and causing symptoms.

To address this issue, the nurse should Position the client on their left side. Lying on the left side helps relieve the pressure on the inferior vena cava and improves blood flow. This can alleviate the symptoms and prevent further complications.

Instructing the client to take a brisk walk is not appropriate in this situation, as it may exacerbate the symptoms by increasing heart rate and potentially causing further dizziness or fainting. Checking the client's temperature is not necessary in relation to these symptoms, as they are not indicative of a fever or infection.

Providing the client with a glass of orange juice may be helpful in some situations, such as if the client is experiencing hypoglycemia. However, in this case, the symptoms are likely due to supine hypotension syndrome, and repositioning the client is the priority intervention.