A nurse observes a parent administer a prescribed oral medication to an infant. Which of the following statements indicates a need for further instruction?

Choice A reason: Drive the client to the nearest emergency department

While it might seem helpful to drive the client to the nearest emergency department, it is not the best course of action. The symptoms described—right-sided weakness and slurred speech—are indicative of a possible stroke. Time is critical in stroke management, and emergency services can provide immediate medical intervention and transport to a stroke center, which is essential for the best possible outcome.

Choice B reason: Call emergency services

Calling emergency services is the most appropriate action. The client is exhibiting signs of a stroke, and rapid medical intervention is crucial. Emergency medical services (EMS) can begin treatment en route to the hospital and ensure the client is taken to a facility equipped to handle strokes. This action maximizes the chances of a positive outcome by minimizing delays in treatment.

Choice C reason: Find a location for the client to sit

Finding a location for the client to sit might provide temporary comfort, but it does not address the urgent need for medical intervention. In the case of a suspected stroke, immediate action is necessary to prevent further damage. Sitting the client down does not provide the critical care needed in this situation.

Choice D reason: Obtain the telephone number of the client’s provider

Obtaining the telephone number of the client’s provider is not the priority in an emergency situation like this. While it might be useful information later, the immediate need is to get the client to a hospital as quickly as possible. Contacting the provider can be done after emergency services have been called.

Choice A reason: Discussing the visitation policy is important for the client’s overall hospital experience but does not directly relate to the prevention of postoperative complications. Visitation policies help manage the flow of visitors and ensure the client gets adequate rest, but they do not address specific postoperative risks.

Choice B reason: Instructing the client about the use of a sequential compression device is crucial for preventing deep vein thrombosis (DVT) and pulmonary embolism, which are common postoperative complications. Sequential compression devices (SCDs) help improve blood circulation in the legs, reducing the risk of blood clots forming during periods of immobility after surgery.

Choice C reason: Teaching the client how to use the PCA pump (patient-controlled analgesia) is important for pain management but does not directly prevent postoperative complications. Proper pain management can aid in recovery by allowing the client to move and breathe more effectively, but it is not a primary preventive measure for complications like DVT or infections.

Choice D reason: Reviewing the pain scale helps the client communicate their pain levels effectively, which is important for managing postoperative pain. However, like the PCA pump, it does not directly prevent complications. Effective pain management can contribute to overall recovery but is not a standalone preventive measure.