During an assessment of an anxious client diagnosed with right lower lobe pneumonia, the nurse notes a new onset change in mental status and tachypnea. The latest vital signs for the client are T: 98.4 F; HR: 108; RR: 28; BP: 144/90; Pulse ox: 88%. What is the priority nursing action?

Choice A reason:
Packaged meats, including salami and bacon, are typically high in sodium, which can contribute to increased blood pressure. The American Heart Association recommends that individuals with hypertension limit their sodium intake to no more than 2,300 milligrams per day, with an ideal limit of no more than 1,500 milligrams for most adults². Since packaged meats are often cured with salt, they can significantly contribute to the daily sodium intake, potentially exacerbating hypertension.

Choice B reason:
Grapefruit juice can interact with certain antihypertensive medications, potentially leading to higher levels of the medication in the bloodstream and an increased risk of side effects¹. This interaction occurs because grapefruit juice can inhibit the action of an enzyme that metabolizes medication, leading to an unintended increase in medication levels.

Choice C reason:
Canned soups are often high in sodium, which can contribute to increased blood pressure. Even low-sodium varieties can still contain significant amounts of sodium. It's important for individuals with hypertension to read labels carefully and choose options with the lowest sodium content possible².

Choice D reason:
Fresh fruits are generally recommended for individuals with hypertension. They are rich in potassium, which can help lower blood pressure by balancing out the negative effects of sodium and easing tension in the blood vessel walls¹. Fresh fruits should not be avoided unless there is a specific reason related to another health condition or medication interaction.

Choice E reason:
Fresh shellfish, like fresh fruits, are typically safe for individuals with hypertension to consume. They provide essential nutrients without the added sodium that is found in processed foods. However, it's important to consume them in moderation and to prepare them without adding excessive salt or high-sodium sauces.

Choice a reason:
Including yogurt in the diet can be beneficial for a client experiencing diarrhea related to antibiotic therapy. Yogurt contains probiotics, which are live microorganisms that can provide health benefits when consumed. These probiotics can help restore the balance of good bacteria in the gut that antibiotics may have disrupted, potentially reducing the duration and severity of diarrhea. However, it's important to choose yogurts that contain active probiotics and to be aware that some individuals may not tolerate dairy well during a bout of diarrhea.

Choice b reason:
Administering famotidine 20 mg daily may help with symptoms of gastritis or peptic ulcers but is not directly related to treating antibiotic-associated diarrhea. Famotidine is a histamine-2 blocker used to reduce stomach acid and is not typically used as a treatment for diarrhea. It should be noted that if a patient is experiencing severe diarrhea, the underlying cause should be addressed rather than just managing symptoms.

Choice c reason:
Testing stool for occult blood is generally not a standard intervention for antibiotic-related diarrhea unless there is a suspicion of gastrointestinal bleeding or an infection like C. difficile, which can cause more severe colitis. Occult blood tests are more commonly used for screening for colorectal cancer or diagnosing conditions that cause gastrointestinal bleeding.

Choice d reason:
Arranging for IV administration of the antibiotic instead of the oral route may be considered if the client has severe diarrhea that prevents the absorption of oral medications or if the client is unable to tolerate oral intake[^10^]¹¹¹²¹³¹⁴. However, many antibiotics have excellent oral bioavailability, and switching from IV to oral antibiotics when appropriate can be just as effective and is often preferred due to convenience and lower risk of complications.