A nurse in a health clinic is assisting in the care of a client diagnosed with chlamydia. The client was prescribed azithromycin 1 g PO once. Which of the following allergy findings in the client's history should the nurse report to the provider?

Choice A reason: Decreased blood pressure is not a direct sign of fluid overload; it may indicate hypovolemia or shock. Fluid overload increases intravascular volume, typically raising pressure initially. This finding contradicts the excess fluid state in enteral feeding complications, where the body retains too much water, affecting other systems first.

Choice B reason: Decreased skin turgor suggests dehydration, not fluid overload. In overload, excess fluid accumulates in tissues, potentially causing edema, not poor elasticity. Enteral feeding can lead to overhydration if mismanaged, making turgor an unreliable indicator here, as it reflects fluid deficit rather than the excess seen in this scenario.

Choice C reason: Weight loss occurs with fluid loss or malnutrition, not overload. Fluid overload from enteral feedings causes rapid weight gain due to water retention. This finding opposes the expected physiology of excess fluid, where the body holds onto water, increasing mass, not shedding it as in dehydration.

Choice D reason: Crackles in the lungs indicate fluid overload, as excess fluid from enteral feedings backs up into pulmonary circulation, causing pulmonary edema. This audible sign reflects fluid escaping into alveoli, impairing gas exchange, a common complication when intake exceeds the body’s ability to excrete water effectively.

Choice A reason: Sitting positions the belt restraint safely at the waist, minimizing injury risk. It allows breathing and circulation, critical when managing aggression safely.

Choice B reason: Tying to bed rails restricts mobility excessively, risking injury if the bed moves. Proper restraint secures to a fixed frame, not rails.

Choice C reason: Chest placement impairs breathing, a dangerous error in restraint use. Belt restraints belong at the waist to avoid respiratory compromise.

Choice D reason: Under-clothing application risks skin abrasion and monitoring issues. Restraints over clothes ensure visibility and safety, per standard aggression protocols.