A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication?

Rationale:

A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.

B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.

C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.

D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.

Rationale:

A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.

B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.

C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.