A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Rationale:

• Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep quality and reduce trazodone’s effectiveness in reestablishing a normal sleep pattern.

• Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension, particularly when therapy is initiated. Educating the client to change positions slowly helps prevent dizziness and potential falls caused by sudden drops in blood pressure.

• Instruct client to avoid foods that have been fermented or aged: This instruction applies to MAOIs due to the risk of hypertensive crisis from tyramine, but trazodone is a serotonin antagonist and reuptake inhibitor, not an MAOI.

• Encourage client to sleep until later in the morning: Oversleeping disrupts the circadian rhythm and may worsen fatigue. The goal is to maintain a stable sleep-wake cycle to enhance mood and energy regulation.

• Encourage a regular sleep-wake schedule: Establishing consistent sleep routines supports trazodone’s sedative effects and helps regulate the client’s circadian rhythm, improving overall sleep quality without disrupting normal activity patterns.

• Advise client to notify provider if pregnant: Trazodone is classified as pregnancy category C, meaning potential fetal risks exist. The client should notify the provider to evaluate the safety of continuing or adjusting medication during pregnancy.

• Encourage high-calorie finger foods: The client’s BMI has decreased, and trazodone may cause appetite suppression. Offering convenient, calorie-dense snacks helps maintain adequate nutrition and prevents further weight loss.

Rationale:
A. Sunken fontanels and dry mucous membranes: These findings indicate moderate to severe dehydration, which can quickly become life-threatening in an infant. Prompt notification of the provider is essential to initiate fluid replacement and prevent complications such as hypovolemic shock.

B. Temperature 38° C (100.4° F) and pulse rate 124/min: A low-grade fever and mildly elevated pulse are common in gastroenteritis and typically do not require immediate reporting unless accompanied by other concerning symptoms like poor perfusion or lethargy.

C. Pale and a 24-hr fluid deficit of 30 mL: A fluid deficit of 30 mL over 24 hours is minimal in an infant and not immediately concerning. Monitoring should continue, but urgent reporting is not necessary for this level of deficit.

D. Decreased appetite and irritability: These are expected symptoms of gastroenteritis in infants and can be managed with routine supportive care and monitoring. They are not specific indicators of severe dehydration requiring immediate provider intervention.