A nurse in a primary care clinic is caring for a client.

Complete the following sentence by using the lists of options.

The client is most at risk for developing

.......

due to their

..........

.

A. Lower the head of the client's bed. There is no need to lower the client’s head of the bed in response to receiving glipizide instead of guaifenesin. Glipizide is an oral antidiabetic medication used to lower blood glucose, while guaifenesin is an expectorant for respiratory conditions. Lowering the head of the bed does not address the potential effects of receiving the wrong medication.

B. Check the client for urinary retention. Glipizide does not cause urinary retention. Instead, it stimulates insulin release to lower blood sugar. If hypoglycemia occurs due to an unintentional dose of glipizide, symptoms such as sweating, dizziness, confusion, or tremors are more concerning than bladder dysfunction.

C. Offer the client a carbohydrate snack. Since glipizide lowers blood glucose levels, administering it instead of guaifenesin could result in hypoglycemia, particularly in a client who does not have diabetes. The nurse should monitor for signs of low blood sugar, such as shakiness, confusion, diaphoresis, and dizziness, and provide a fast-acting carbohydrate (e.g., juice, crackers, or glucose tablets) if symptoms develop.

D. Test the client’s deep-tendon reflexes. Glipizide does not affect neuromuscular function or deep-tendon reflexes. While severe hypoglycemia can cause altered mental status or seizures, routine reflex testing is not necessary for monitoring the effects of an incorrect glipizide administration.

A. Add the medications to the enteral feeding bag. Medications should not be mixed with enteral feeding formula as this can alter drug absorption, cause tube clogging, or result in medication interactions. Each medication should be administered separately to ensure proper effectiveness.

B. Check for gastric residual 15 min after administering the medications. Gastric residual volume (GRV) should be checked before medication administration to assess delayed gastric emptying. Checking it after administration is unnecessary and may disrupt medication absorption without clinical benefit.

C. Keep the client's head elevated 15° while administering the medications. The head of the bed should be elevated at least 30–45 degrees, not 15 degrees, to reduce aspiration risk and promote medication passage. Insufficient elevation increases the likelihood of regurgitation and aspiration pneumonia.

D. Flush the tube with 30 ml of water between each medication. Flushing with 30 mL of water between medications prevents tube clogging and ensures each drug is properly delivered. It also minimizes drug interactions by preventing medications from mixing within the tube.