The nurse observes a student nurse administer 100 mg phenytoin (Dilantin) suspension and 20 mg famotidine (Pepcid) solution through a gastrostomy tube. The client receives an enteral feeding through the gastrostomy tube at a rate of 75 mL/h. Which action by the student nurse requires an IMMEDIATE intervention by the nurse?

Choice A reason: Octreotide reduces portal hypertension and bleeding in esophageal varices by constricting splanchnic blood flow. This aligns with acute variceal bleed management, making it the correct medication the nurse would expect to be administered to the actively bleeding client.

Choice B reason: Propranolol prevents variceal bleeding long-term but is not used for active bleeding. Octreotide is acute treatment, making this incorrect, as it’s inappropriate for the nurse’s expectation in managing the client’s immediate esophageal variceal hemorrhage.

Choice C reason: Lactulose treats hepatic encephalopathy, not active variceal bleeding. Octreotide controls acute hemorrhage, making this incorrect, as it’s unrelated to the nurse’s priority of administering a medication to stop the client’s esophageal variceal bleeding in the emergency.

Choice D reason: Spironolactone manages ascites in liver disease, not acute variceal bleeding. Octreotide is the treatment for active bleeding, making this incorrect, as it’s irrelevant to the nurse’s expectation for a medication to control the client’s esophageal variceal hemorrhage.

Choice A reason: Initiating antibiotics is critical but follows cultures to identify the causative organism. Obtaining cultures first ensures accurate treatment, making this incorrect, as it risks altering culture results if antibiotics are given before sampling in the pneumonia client.

Choice B reason: Obtaining blood and sputum cultures first identifies the pneumonia-causing organism, guiding effective antibiotic therapy. This aligns with infection management protocols, making it the correct initial order to implement for the client admitted with pneumonia to ensure accurate treatment.

Choice C reason: Airborne precautions are needed for specific pneumonias (e.g., tuberculosis), but most require droplet precautions. Cultures guide treatment, making this incorrect, as it’s less urgent than obtaining cultures first to confirm the pathogen in the client with pneumonia.

Choice D reason: An indwelling catheter is unnecessary for pneumonia unless urinary retention is present. Obtaining cultures is the priority, making this incorrect, as it’s irrelevant to the immediate management of the client’s infection compared to identifying the causative organism.