The nurse is caring for a client with cirrhosis, portal hypertension, and esophageal varices. Which of the following is not a potential intervention?

A. A client admitted with pancreatitis who is requesting pain medication: While pancreatitis causes severe pain, this is not the highest priority. Pain management is important, but it does not indicate an immediate life-threatening issue.

B. A client post a liver biopsy who has tachycardia and is restless: Tachycardia and restlessness following a liver biopsy may indicate internal bleeding due to liver puncture. The liver is highly vascular, and hemorrhage is a serious complication requiring immediate assessment.

C. A client admitted with ulcerative colitis who is requesting an anti-diarrheal: While diarrhea is distressing, this is not life-threatening. The client can be seen after addressing the higher-priority client.

D. A client postop day 1 with dark red drainage the size of a dime on the dressing: Small amounts of dark red drainage are expected postoperatively. This client does not require immediate attention.

A. Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr: Fluid resuscitation is important, but potassium should not be administered until electrolyte levels are assessed. Also, potassium administration in a client with a bowel obstruction requires caution due to the risk of hyperkalemia if renal function is impaired.

B. Insert a nasogastric tube: A nasogastric (NG) tube is essential in managing bowel obstruction as it helps decompress the stomach, relieve pressure, and prevent aspiration. This should be done first to stabilize the client.

C. Draw a basic metabolic panel: Checking electrolyte imbalances is important but should be done after stabilizing the client with NG tube insertion.

D. Ambulate in the hallway: Ambulation is contraindicated in acute bowel obstruction due to the risk of worsening symptoms such as nausea, vomiting, and severe pain.