A nurse is caring for a client with a blood glucose of 42 mg/dL who is confused and diaphoretic.
Which of the following are the priority nursing interventions?

Choice A rationale

The clinical presentation of elevated blood pressure, tachypnea, and decreased oxygen saturation strongly suggests fluid volume overload. New onset crackles in the lungs and pitting edema are classic indicators of pulmonary congestion and systemic fluid retention. In a 72-year-old patient receiving hypertonic saline for hyponatremia, the risk of rapid fluid shifts into the intravascular space is high. Prompt notification of the provider is essential to adjust the infusion and prevent further respiratory or cardiac compromise.

Choice B rationale

Continuing to monitor without intervention is inappropriate and dangerous when a client shows active signs of respiratory distress and cardiovascular strain. Monitoring is a secondary action that must follow immediate clinical intervention or notification of the medical team. The presence of crackles and a drop in oxygen saturation to 91 percent indicates that the current treatment plan is causing harm. Waiting longer could lead to acute pulmonary edema or heart failure in an elderly patient with limited cardiac reserve.

Choice C rationale

Increasing the fluid rate would exacerbate the existing fluid volume excess and worsen the client's condition. Hypertonic solutions draw intracellular fluid into the extracellular space, rapidly increasing circulating volume. The patient is already showing signs that the heart cannot handle the current volume, as evidenced by the 1.2 kg weight gain and edema. Further increasing the rate would likely lead to severe hypertension and life-threatening respiratory failure due to worsening pulmonary congestion and alveolar flooding.

Choice D rationale

Requesting anti-anxiety medication addresses a symptom rather than the underlying physiological cause of the restlessness. The client's confusion and restlessness are most likely secondary to hypoxia and cerebral changes from fluid shifts or hyponatremia. Administering a sedative could mask worsening neurological status and potentially depress the respiratory drive in a patient already struggling with oxygenation. The priority must be correcting the fluid imbalance and improving oxygenation through appropriate medical management of the overload.

Choice A rationale

Promethazine is an antihistamine with potent antiemetic properties often used in the postoperative setting to manage nausea and vomiting. The intravenous route is appropriate for a patient who is actively vomiting and unable to tolerate oral intake. By blocking dopamine receptors in the chemoreceptor trigger zone, it effectively reduces the vomiting reflex. Since the patient is in the PACU and actively emetic, parenteral administration ensures rapid onset of action and reliable systemic absorption.

Choice B rationale

Ondansetron is a highly effective 5-HT3 receptor antagonist used for postoperative nausea. however, the oral route is contraindicated for a patient who is actively vomiting. If a patient cannot keep fluids down, a pill or disintegrating tablet will likely be expelled before it can be absorbed in the gastrointestinal tract. In the immediate postoperative phase with active emesis, the nurse must prioritize non-oral routes, such as intravenous or intramuscular, to achieve therapeutic effects.

Choice C rationale

Acetaminophen administered rectally is an analgesic and antipyretic medication. While it bypasses the oral route, it does nothing to address the patient's primary distress, which is active vomiting. The question asks for an appropriate medication for a patient who is vomiting, and Tylenol lacks antiemetic properties. Using a rectal suppository for pain might be a secondary consideration, but it does not treat the underlying gastric distress or the risk of aspiration and dehydration.

Choice D rationale

Ibuprofen is a nonsteroidal anti-inflammatory drug used for pain and inflammation. Like other oral medications, it is inappropriate for a patient experiencing active emesis. Furthermore, NSAIDs can cause gastric irritation, which might worsen the patient's nausea. In the postoperative period, especially following a cholecystectomy, maintaining a patent airway and stopping vomiting is the priority. Giving an oral medication during active vomiting is ineffective and increases the risk of the patient choking or inhaling vomitus.