A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

The correct answer is D.

Verify the medication three times with the medication administration record. The nurse should follow the six rights of medication administration: right client, right drug, right dose, right route, right time, and right documentation. To ensure the right drug and dose, the nurse should check the medication label against the medication administration record (MAR) three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.

The nurse should also use two identifiers (such as name and date of birth) to verify the right client. The nurse should document medication administration after giving the medication, not before, to avoid errors and ensure accuracy. The nurse should administer time-critical medications within 30 minutes before or after the scheduled time, not 60 minutes.

The correct answer is B. Productive cough with thick mucus. Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis bacteria. It causes severe coughing spells that can interfere with breathing and produce a characteristic whooping sound when inhaling. The cough may also be accompanied by thick mucus that can be difficult to clear. Therefore, a nurse should expect to see a productive cough with thick mucus as a manifestation of pertussis in a child. The other options are not typical manifestations of pertussis, but rather of other conditions. A beefy, red tongue may indicate vitamin B12 deficiency or pernicious anemia. Facial erythema may indicate fever, allergy, or inflammation. Peeling of the hands and feet may indicate Kawasaki disease, a rare inflammatory disorder that affects the blood vessels.