A nurse is caring for a client in the emergency department.

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Nurses notes:

1400:

Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)

Vital signs:

1400:

Temperature 36.8° C (98.2 F)

Pulse rate 84/min

Respiratory rate 16/min

Blood pressure 106/76 mm Hg

Oxygen saturation 96% on room air

Rationale

Interpretation of Actions:

• Encourage the client to cough:
  • Nonessential
    Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
• Initiate seizure precautions:
  • Anticipated
    Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
• Elevate the head of the bed:
  • Anticipated
    Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
• Keep the client's head in a midline position:
  • Anticipated
    Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
• Decrease oxygen to 1.5 L/min via nasal cannula:
  • Contraindicated
    Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
• Assist the client to the bathroom:
  • Contraindicated
    Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.

A. Diphenhydramine is an antihistamine and is primarily used for allergy symptoms or as a sedative. While it has anti-nausea properties, it is not the most effective medication for chemotherapy-induced nausea and vomiting.

B. Sertraline is an SSRI used primarily for depression and anxiety. It is not typically used for chemotherapy-induced nausea and vomiting.

C. Ondansetron is the most appropriate medication. It is a serotonin 5-HT3 receptor antagonist commonly used to prevent nausea and vomiting caused by chemotherapy. It works by blocking serotonin receptors in the gastrointestinal tract and central nervous system, preventing nausea.

D. Methylprednisolone is a corticosteroid and may be used as part of a combination regimen to manage nausea and vomiting associated with chemotherapy, but it is not the first-line medication for nausea. Ondansetron would typically be given first.