A nurse is reinforcing client teaching about preventing stress injuries. Which of the following statements by the client indicates an understanding of teaching?

Rationale:

A. Mix the medication in juice prior to administration: Montelukast can be mixed with soft foods like applesauce, but mixing it in juice is not specifically recommended due to potential taste masking and dosing accuracy issues. Instructions should follow the manufacturer’s guidelines.

B. Administer the medication when the toddler has an acute asthma attack: Montelukast is a maintenance medication used to prevent asthma symptoms and is not effective for treating acute asthma attacks. A rescue inhaler like albuterol should be used during acute episodes.

C. Provide an additional dose of the medication prior to physical activity: Montelukast is not typically dosed in response to physical activity. While it can help prevent exercise-induced bronchospasm, it should be taken once daily in the evening, not additionally before exertion.

D. Administer the medication to the toddler each evening: Montelukast is prescribed as a once-daily maintenance therapy and is most effective when given in the evening. This helps maintain consistent blood levels and prevents nighttime asthma symptoms.

Rationale:

A. Apply a warm compress: Applying a warm compress may help promote absorption of infiltrated fluid and reduce discomfort, but it should not be the initial action. Warm compresses are appropriate only after the infusion is stopped and proper assessment is completed.

B. Stop the infusion: The first priority when infiltration is suspected—evidenced by cool, edematous skin—is to stop the infusion immediately. Continuing the infusion could lead to worsening tissue damage or complications depending on the type of fluid or medication.

C. Document the infiltration: Documentation is necessary but not the immediate priority. It should follow prompt clinical action to stop the infusion and prevent further harm to the surrounding tissue.

D. Elevate the arm: Elevating the arm can help reduce edema, but this supportive measure should be done only after the infusion has been stopped. It does not address the root cause or prevent further infiltration.