Sublingual nitroglycerin is prescribed PRN for an older adult female client with a history of chest pain. The client shows the practical nurse (PN) a plastic pill box that she purchased so the medication can always be readily available in her purse. Which action should the PN take?

Choice A reason: Rivaroxaban, a direct oral anticoagulant, inhibits factor Xa, increasing bleeding risk. Bruising on arms and legs may indicate excessive anticoagulation, potentially leading to severe hemorrhage. Immediate reporting is critical to assess bleeding risk, adjust dosing, or initiate interventions to prevent life-threatening complications.

Choice B reason: Genital itching and burning with discharge suggest a possible infection or allergic reaction, not a direct adverse effect of rivaroxaban. These symptoms are unrelated to its anticoagulant mechanism, which primarily affects hemostasis, making this choice incorrect for immediate reporting.

Choice C reason: Diminished taste and smell are not recognized side effects of rivaroxaban. These symptoms may relate to other conditions, like neurological or infectious issues, but do not reflect the drug’s anticoagulant effects. This choice is irrelevant to rivaroxaban’s adverse effect profile.

Choice D reason: Hard, dry stools indicate constipation, a non-urgent side effect not typically associated with rivaroxaban. While gastrointestinal issues may occur, bleeding risks are more critical. This symptom does not warrant immediate reporting compared to bruising, which signals potential hemorrhage.

Choice A reason: Recording blood pressures is relevant, as diazepam may cause hypotension, but it is less critical than respiratory monitoring. Status epilepticus requires rapid seizure control, and diazepam’s respiratory depression risk is more immediate, as it can lead to life-threatening hypoxia if not addressed promptly.

Choice B reason: Measuring urinary output monitors renal function but is not urgent in status epilepticus. Diazepam’s primary risk is respiratory depression, not renal effects. Ensuring airway and breathing stability is more critical, as seizures and the drug both threaten respiratory function, making this choice secondary.

Choice C reason: Monitoring respiratory rate and effort is critical, as diazepam, a CNS depressant, can cause respiratory depression, especially in status epilepticus, where seizures already compromise breathing. Hypoventilation risks hypoxia, potentially leading to brain damage or death, making this the most urgent intervention to ensure airway safety.

Choice D reason: Observing eye deviation may indicate ongoing seizures but is less urgent than respiratory monitoring. Diazepam controls seizures, but its side effect of respiratory depression poses an immediate threat. Ensuring adequate ventilation is the priority to prevent hypoxia during acute seizure management.