# Stage 5 — Take action. The child is afebrile 24 hours after IVIG and is receiving aspirin. The LAD coronary Z-score was 2.7. The nurse prepares discharge teaching for the caregiver. Classify each situation the caregiver might report after discharge by the response the nurse should teach. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617241&lang=en > language: en > subject: Accident/Error/Injury Prevention > category: SIPC ## Question Stage 5 — Take action. The child is afebrile 24 hours after IVIG and is receiving aspirin. The LAD coronary Z-score was 2.7. The nurse prepares discharge teaching for the caregiver. Classify each situation the caregiver might report after discharge by the response the nurse should teach. **1.** Temperature 38.4 C on the second day at home Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day **2.** Skin peeling from the fingertips during the second week Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day **3.** Sudden pallor, sweating, and inconsolable crying Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day **4.** A nosebleed that stops after 5 minutes of firm pressure Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day **5.** An older sibling is diagnosed with influenza Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day **6.** The clinic offers the inactivated influenza shot this fall Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day **7.** Hard to wake, breathing fast, and cool, mottled legs Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day **8.** Refuses chewable aspirin; only ibuprofen is at home Select a category Call emergency services now Expected; continue the home plan Call the cardiology team the same day ## Explanation Periungual peeling in week 2, a brief nosebleed controlled with pressure on aspirin, and an inactivated influenza vaccine are expected or recommended. Recurrent fever (possible treatment failure), influenza exposure while on aspirin (Reye syndrome risk), and inability to take aspirin when only ibuprofen is available (ibuprofen antagonizes aspirin's antiplatelet effect) need a same-day call, while pallor, sweating, and inconsolable crying or poor perfusion in a child with a coronary aneurysm may signal myocardial ischemia or shock and require emergency services. ## In-depth explanation Quick answer Expected: fingertip peeling, a nosebleed that stops with pressure, inactivated flu shot. Same day: fever 38.4 C, sibling with influenza, refusing aspirin with only ibuprofen at home. Emergency: sudden pallor, sweating, and inconsolable crying; hard to wake with fast breathing and mottled legs. Why this is correct Each situation is sorted by the specific risk it creates for a child with a small coronary aneurysm on aspirin. Periungual desquamation is a normal subacute finding. Aspirin causes minor bleeding, which is concerning only if it does not stop. Fever after discharge may mean recrudescent disease that needs evaluation today. Influenza exposure raises Reye syndrome risk, and ibuprofen blocks aspirin's antiplatelet effect, so both need a same-day prescriber decision. In young children, myocardial ischemia presents as pallor, diaphoresis, irritability, and inconsolable crying rather than chest pain. Easy analogy or mental picture Sort like a triage desk: things that are part of the healing script, things that change the medication plan today, and things that mean the heart is in trouble right now. Memory hook Toddler heart attack = pale, sweaty, screaming, not chest pain. NCLEX decision rule For discharge teaching after Kawasaki disease, link each report to aneurysm risk, aspirin safety, or treatment failure, and choose the urgency from that link rather than from how alarming the finding looks. Why the other choices are wrong Peeling skin and a nosebleed look alarming to caregivers and are often over-triaged, but they are expected and self-limited here. The inactivated flu shot is tempting to classify as a problem because live vaccines are delayed after IVIG, but inactivated influenza vaccine is recommended for children on aspirin. Fever at home is tempting to send to emergency services, but in a hemodynamically stable child it needs same-day evaluation, not an ambulance. The sibling's influenza and the ibuprofen substitution look minor but change the safety of the aspirin plan. Pallor with sweating and inconsolable crying is easy to dismiss as a tantrum, which is why it is the key emergency cue. References 1AHA Scientific Statement: Diagnosis, Treatment, and Long-Term Management of Kawasaki DiseaseAspirin therapy, ibuprofen interaction, influenza and Reye syndrome precautions, inactivated influenza vaccination, desquamation, recrudescent fever, and ischemia risk with coronary aneurysm 2CDC: Kawasaki DiseaseKawasaki disease course, coronary complications, and follow-up care ## Clinical scenario Case update The child becomes afebrile after IVIG. The nurse begins discharge teaching while observation continues. ## Key concepts - **Periungual desquamation** — Peeling of skin around the fingernails and toenails that typically appears in the second to third week of Kawasaki disease. - **Aspirin-ibuprofen interaction** — Ibuprofen can block aspirin from binding platelets and reduce its antiplatelet protection. - **Pediatric myocardial ischemia** — In young children it often appears as pallor, sweating, vomiting, and inconsolable crying rather than reported chest pain. ## Related questions - [A circulating nurse leads the final time-out for an operative procedure. 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