A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?

Choice A Reason

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. While pain management is important, this client is not in immediate life-threatening danger. Pain can be addressed after ensuring there are no urgent allergic reactions or other critical conditions.

Choice B Reason

A client who received parenteral cephalosporin and reports urticaria and edema. This is the correct choice. Urticaria (hives) and edema (swelling) can indicate an allergic reaction, which can progress to anaphylaxis, a life-threatening condition. Immediate assessment and intervention are required to prevent severe complications.

Choice C Reason

A client who is being admitted with bilateral stage 3 pressure injuries on both heels. While stage 3 pressure injuries are serious and require prompt attention, they do not pose an immediate life-threatening risk compared to a potential anaphylactic reaction.

Choice D Reason

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F). Although a systemic infection with a high fever is concerning and needs timely intervention, it is not as immediately life-threatening as a potential anaphylactic reaction.

Choice A Reason

Initiate insulin drip. This intervention is not typically included in the standard care plan for all patients with acute pancreatitis. Insulin drips are generally reserved for cases of hypertriglyceridemia-induced pancreatitis, where insulin helps to lower triglyceride levels. For most patients with acute pancreatitis, this is not a standard intervention.

Choice B Reason

Monitor blood glucose levels. This is a correct intervention. Acute pancreatitis can affect the pancreas’ ability to regulate blood sugar, leading to hyperglycemia or hypoglycemia. Monitoring blood glucose levels helps in managing these potential complications and ensuring appropriate treatment.

Choice C Reason

Continue regular diet as tolerated. This statement is incorrect. Patients with acute pancreatitis are usually kept NPO (nothing by mouth) initially to rest the pancreas. Once the inflammation subsides, they may gradually reintroduce oral intake starting with clear liquids and progressing to a low-fat diet.

Choice D Reason

Maintain NPO status until pain-free. This is partially correct but not entirely accurate. While initial management often includes NPO status to rest the pancreas, current guidelines suggest that early enteral feeding can be beneficial and should be started as soon as tolerated. Prolonged NPO status is no longer the standard of care.

Choice E Reason

Manage acute pain. This is a correct intervention. Pain management is a critical component of care for patients with acute pancreatitis. Effective pain control improves patient comfort and can help reduce the stress response associated with severe pain.