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: Tongue furrows indicate dehydration but don’t assess ambulation safety, which requires hemodynamic stability. Orthostatic blood pressure changes are key, making this incorrect, as it’s less relevant than the nurse’s priority to evaluate fall risk in a dehydrated client.

Choice B reason: Comparing blood pressure in lying, sitting, and standing positions detects orthostatic hypotension, a fall risk in dehydrated older clients. This aligns with mobility safety assessment, making it the correct action to determine if the client is safe for independent ambulation.

Choice C reason: Serum potassium above 3.5 mEq/L ensures cardiac stability but doesn’t directly assess ambulation safety. Orthostatic changes are more relevant, making this incorrect, as it’s not the nurse’s primary focus for evaluating mobility in a dehydrated client.

Choice D reason: Radial and apical pulse consistency checks pacemaker function, not ambulation safety in dehydration. Blood pressure changes are critical, making this incorrect, as it’s unrelated to the nurse’s assessment of safe independent ambulation in the dehydrated older client.

Choice A reason: Monitoring for further occurrences is passive and doesn’t address the immediate breach of confidentiality. Advising to stop the conversation protects the client, making this incorrect, as it delays the nurse’s priority of halting the unethical discussion promptly.

Choice B reason: Advising the nurses to cease their communication is the first action to stop the breach of client confidentiality in a public setting. This aligns with ethical and privacy standards, making it the correct initial step for the newly licensed RN to take.

Choice C reason: Informing the manager is important but secondary to stopping the conversation to prevent further disclosure. Advising to cease is immediate, making this incorrect, as it’s not the first action the RN should take to address the confidentiality breach.

Choice D reason: Submitting a report follows stopping the conversation and notifying the manager. Advising to cease is the first step, making this incorrect, as it delays the RN’s priority of immediately halting the nurses’ inappropriate discussion about the client.