A school nurse is developing a program to promote healthy eating in school-age children. Which of the following interventions should the nurse include? (Select all that apply)

Rationale:

A. Remove stopcocks from IV tubing: Removing stopcocks is not necessary and may compromise IV line function. The priority is to prevent contact with latex-containing components, not to eliminate all IV hardware, as many are latex-free.

B. Disinfect and powder any latex products before use: Powdered latex products increase the risk of airborne latex particles, which can trigger severe allergic reactions. Disinfecting or using powdered latex items is unsafe for clients with latex sensitivity and should be avoided entirely.

C. Tape stockinet over monitoring devices and cords: Covering monitoring devices, cords, and other equipment with a barrier such as stockinet prevents direct contact with latex-containing components. This reduces the risk of an allergic reaction during surgery while allowing the necessary monitoring and functionality to continue safely.

D. Schedule the client as the last surgery of the day: While scheduling considerations may be made to reduce exposure to residual latex or disinfectants, the timing of surgery is not the primary strategy for preventing a reaction. The focus should be on removing or isolating all latex-containing items from the environment.

Rationale for correct choices

• Neurological: Reports that dizziness and palpitations started 2 months ago: Persistent dizziness and palpitations may indicate arrhythmias, decreased cardiac output, or early cardiovascular compromise. Although the client is alert and oriented, these symptoms suggest insufficient cerebral perfusion or possible underlying cardiac pathology that requires further evaluation.

• Cardiovascular: Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally, Capillary refill time 5 seconds for all extremities: Diminished pulses, mild edema, and prolonged capillary refill time indicate potential peripheral arterial insufficiency and early signs of fluid overload or heart failure. These findings suggest impaired circulation and warrant further assessment.

• Respiratory: Fatigue and dyspnea with exertion started 1 week ago: New-onset exertional dyspnea and fatigue may be early indicators of compromised cardiac or pulmonary function. Despite clear lung sounds, these symptoms suggest reduced oxygen delivery or early heart failure. Prompt evaluation is required to prevent progression and to identify reversible causes.

• Vital Signs: Heart rate 105/min, Blood pressure 164/92 mm Hg: Tachycardia and hypertension indicate increased cardiac workload and potential risk for end-organ damage. Persistent elevated BP above 140/90 mm Hg is associated with cardiovascular complications, including left ventricular hypertrophy and renal impairment. Monitoring and further evaluation of cardiac function, lifestyle factors, and medication adherence are necessary.

Rationale for incorrect choices

• Neurological: Alert and oriented to person, place, and time: Being alert and oriented reflects intact cognitive function and does not require immediate further evaluation. While neurological changes may arise secondary to cardiac issues, orientation alone is within normal limits and is not concerning. This finding does not indicate acute pathology.

• Respiratory: Lungs clear to auscultation bilaterally: Clear lung sounds suggest no active pulmonary congestion, infection, or obstruction. Although dyspnea is present, the absence of adventitious lung sounds indicates that the respiratory system is not acutely compromised. Further evaluation focuses on cardiac or systemic causes rather than pulmonary pathology.