The nurse plans to administer the adult client’s prescriptions which are metoprolol, hydrochlorothiazide, enoxaparin and atorvastatin.

The current laboratory values are; Serum potassium 5.2 mmol/L, Platelet Count 98,000/mm, Serum cholesterol 250 mg/dL and Serum Creatinine 1.2 mg/dL.
Which medication should the nurse hold and notify the prescriber?

This is essential because drainage from a large abdominal wound may collect under the client and be missed if only the dressing is inspected. The amount, color, and consistency of drainage should be documented and reported to the health care provider.

Choice A is wrong because feeling the top of the client’s legs will not help assess for drainage in a large abdominal wound.

Choice C is wrong because asking the client to cough forcefully may increase the risk of dehiscence (separation of wound edges) or evisceration (protrusion of internal organs through the wound) in a large abdominal wound.

Choice D is wrong because having the client sit up and lean forward may also increase the risk of dehiscence or evisceration in a large abdominal wound.

Normal ranges for wound drainage depend on the type, location, and size of the wound, as well as the stage of healing. Generally, drainage should decrease over time and change from bloody to serous.

This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.

The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.

Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.

Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.

Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.