nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps, placing them in the selected order of performance. Use all the steps.)

A. "This medication can cause nausea and drowsiness.": Gastrointestinal upset, including nausea, and central nervous system effects such as drowsiness or mild tremor are common early adverse effects of lithium. Clients should be monitored for symptom severity and reassured that these effects often diminish over time.

B. "You will be placed on a low-sodium diet while taking this medication": Lithium excretion is highly dependent on sodium levels; however, clients are advised to maintain a consistent, adequate sodium intake rather than restricting sodium. A low-sodium diet can increase lithium retention and risk toxicity.

C. "It will take at least a week before this medication reaches a therapeutic level.": Lithium requires several days to reach a steady-state concentration in the blood. Clients and caregivers should understand that therapeutic effects on mood stabilization may not be immediate, and monitoring serum levels is necessary.

D. "This medication can cause weight gain.": Weight gain is a recognized long-term adverse effect of lithium therapy, likely related to metabolic changes and fluid retention. Clients should be counseled on healthy diet and activity to help mitigate this effect.

E. "Blurred vision is an expected adverse effect of this medication": Blurred vision is not an expected or common side effect of lithium. If it occurs, it may indicate toxicity or another ophthalmologic issue, requiring immediate evaluation.

Rationale for correct choices

• Pneumonia: The child is at risk for postoperative pneumonia due to shallow breathing and refusal to use the incentive spirometer. Postoperative pain can limit deep breathing, decreasing alveolar expansion and promoting secretion retention. This immobility of airways increases the likelihood of atelectasis, which can progress to pneumonia if preventive measures are not implemented.

• Shallow breathing: Shallow respirations reduce tidal volume and limit lung expansion, contributing to alveolar collapse and secretion accumulation. This is a common postoperative risk, particularly in children reluctant to take deep breaths due to abdominal pain. Monitoring and encouraging deep breathing can help prevent pulmonary complications.

• Lack of incentive spirometer use: Refusal to use the incentive spirometer reduces lung expansion, promoting atelectasis and increasing risk for infection. Incentive spirometry is essential to prevent postoperative pulmonary complications.

Rationale for incorrect choices

• Postoperative ileus: Absent bowel sounds are expected in the immediate postoperative period and are not abnormal within the first several hours after abdominal surgery. The child’s abdominal tenderness and soft abdomen are consistent with normal post-surgical recovery. Ileus becomes a concern if bowel sounds remain absent beyond 24–48 hours or if the child develops vomiting or abdominal distention.

• Peritonitis: The child shows no signs of systemic infection, rebound tenderness, or rigid abdomen. The incision is dry and intact, and vital signs are stable with only mild temperature elevation. Peritonitis would present with diffuse abdominal pain, guarding, and often fever, none of which are present.

• Breath sounds: Breath sounds are clear throughout, indicating no active pneumonia at this time. While lung expansion is limited, auscultation does not show crackles, wheezing, or other abnormal findings. Breath sounds alone do not indicate risk; shallow breathing and incentive spirometer non-use are more predictive of pulmonary complications.

• Absent bowel sounds: In the immediate postoperative period, bowel sounds may be decreased or absent for several hours due to anesthesia and surgical manipulation. This finding should not be interpreted as abnormal at this stage.