The parents of an infant with chronic health conditions have cognitive challenges and diverse educational backgrounds. Which intervention(s) should the nurse implement to support them in safely administering medications to their child? Select all that apply.

Rationale for correct choices:

• Pain: The client reports a pain level of 10/10 in the left arm, described as sharp and constant. Pain at this severity requires urgent management because uncontrolled pain can impair mobility. Immediate intervention for pain ensures comfort and supports further diagnostic and therapeutic procedures.

• Compartment syndrome: Findings of swelling, decreased sensation, coolness of the skin, and diminished left radial pulse suggest compromised circulation. These are classic warning signs of compartment syndrome, a limb-threatening complication caused by increased pressure within a muscle compartment.

Rationale for incorrect choices:

• Mobility: While the client’s long-term recovery will require mobility interventions, it is not the immediate priority in the acute emergency setting. Pain and neurovascular compromise take precedence over mobility at this stage because they directly affect safety and circulation.

• Swelling: Swelling is a significant concern, but it is a symptom rather than the priority need. Addressing pain and preventing complications such as compartment syndrome will indirectly reduce swelling by improving circulation and managing tissue injury.

• Venous thromboembolism: The client’s high BMI and reduced mobility put him at risk for VTE, but this is a longer-term complication. It does not outweigh the immediate need to manage severe pain and monitor for compartment syndrome, which can cause rapid tissue necrosis.

• Fat embolism syndrome: Fat embolism is a possible complication of long bone fractures, but there is no evidence here of a femoral fracture or respiratory distress. Although his weight and orthopedic history are risk factors, the current findings point more strongly toward compartment syndrome.

• Temperature 98.1°F (36.7°C): Afebrile status indicates that the body is not mounting a febrile response to pathogens, showing infection is being prevented postoperatively.

• pH 7.40: Normal pH reflects adequate perfusion and circulation after fluid resuscitation, suggesting hypovolemia has been managed effectively.

• Blood pressure 112/77 mm Hg: Stable blood pressure within normal range after fluid bolus demonstrates restoration of circulating volume, consistent with hypovolemia management.

• Capillary refill 2 seconds: Normal refill indicates improved tissue perfusion after fluid therapy, confirming adequate correction of hypovolemia.

• Pain 0 on a scale of 0 to 10: Absence of reported pain while sedated indicates comfort and relief of anxiety, showing pain control is being achieved.

• Surgical dressing dry and intact: A clean, dry surgical site without drainage supports the goal of preventing infection after abdominal trauma surgery.

• PaCO2 42 mm Hg: PaCO 2 of 42mmHg is within the normal range (35−45mmHg) and indicates effective ventilation. This is primarily an ABC or respiratory goal, not directly related to the three listed goals.