A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Rationale:

A. Position the child at a 10° to 20° angle after feeding: This angle is too low to effectively reduce the risk of aspiration. The child should remain in at least a 30° to 45° upright position during and after feeding for optimal safety.

B. Measure the tubing from the nose to the distal port: Correct placement measurement involves determining the appropriate tube length from the tip of the nose to the earlobe and then to the xiphoid process. Measuring to the distal port ensures accurate placement for safe feeding.

C. Warm the formula in the microwave: Microwaving can create uneven heating and hot spots that may burn the gastrointestinal mucosa. Formula should be warmed by placing the container in warm water and checking the temperature before administration.

D. Complete the feeding in 5 min: Rapid feeding increases the risk of nausea, vomiting, and aspiration. Feedings should be administered slowly over the recommended time frame to allow for tolerance and digestion.

Rationale for correct choices:

• Blood pressure: The client’s blood pressure is 90/50 mm Hg, indicating hypotension. This can signal volume depletion or active bleeding, which requires immediate assessment and intervention to prevent shock or organ hypoperfusion.
• Hemoglobin and hematocrit: Hemoglobin of 9.1 g/dL and hematocrit of 27% indicate significant anemia, likely from gastrointestinal blood loss. Immediate follow-up is necessary to determine the source and provide interventions such as fluid resuscitation or transfusion.
• Heart rate: The client’s heart rate is 118/min, demonstrating tachycardia. This may be compensatory for hypotension or blood loss, suggesting hemodynamic instability and requiring prompt monitoring and intervention.
• Stool results: Positive hemoccult indicates gastrointestinal bleeding, which aligns with anemia and tachycardia. Identifying and managing the bleeding source is a priority to prevent further complications.
• Current medication: The client takes high-dose ibuprofen (800 mg three times daily), a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs increase the risk for peptic ulcer disease and gastrointestinal bleeding, contributing to the client’s current presentation and requiring immediate provider notification.

Rationale for incorrect choices:

• Temperature: The client’s temperature is 37.5° C (99.5° F), slightly elevated but not indicative of infection or immediate risk. Monitoring is appropriate but not urgent.
• WBC count: WBC is 6,700/mm³, within normal limits, indicating no current infection or acute inflammatory response. This does not require immediate follow-up.
• Respiratory rate: Respiratory rate is 18/min, within normal limits for an adult, and does not indicate acute respiratory distress. Immediate intervention is not necessary.