A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

A. Notify the client's provider: Notifying the provider is important if there is concern for injury, but this should follow the initial assessment to determine the client’s condition. Immediate evaluation takes priority to identify any life-threatening or urgent issues.

B. Measure the client's vital signs: Assessing vital signs is the first action because it provides critical information about the client’s hemodynamic status and identifies potential injuries or complications, such as internal bleeding or shock, following the fall. This guides subsequent interventions and provider notification.

C. Complete an incident report: Completing an incident report is necessary for legal and quality improvement purposes, but it is not the first priority. The client’s safety and clinical assessment take precedence over documentation.

D. Document the fall in the client's medical record: Accurate documentation is essential for continuity of care and legal reasons, but it should occur after assessing the client’s condition and initiating any necessary interventions.

A. Pain rating of 4 on a scale of 0 to 10: Mild to moderate pain is expected in the early postoperative period due to surgical trauma. While pain should be monitored, a rating of 4 is not specific for infection and can be considered within normal postoperative discomfort.

B. Temperature of 37.2° C (99.0°F): A slightly elevated temperature within the normal range is common after surgery due to inflammatory response. It does not necessarily indicate infection unless it continues to rise or is accompanied by other systemic signs.

C. Increased urinary output: Increased urine output is generally a positive sign of adequate renal perfusion and fluid balance. It is not indicative of infection and may instead reflect normal postoperative recovery or fluid administration.

D. Elevated WBC count: Leukocytosis is a key laboratory indicator of infection. An elevated white blood cell count suggests an inflammatory or infectious process, which is particularly concerning in the postoperative period and warrants further assessment and intervention.