A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

A Furosemide is likely to cause hypotension rather than hypertension.

B. Limiting salt intake is highly recommended while on furosemide because excess sodium can cause the body to retain water, which can worsen fluid retention and undermine the effectiveness of the diuretic.

C. Checking the pulse is important for certain medications that can affect heart rate, like beta-blockers. However, furosemide is not typically associated with major effects on pulse rate.

D. While increasing potassium-rich foods such as cantaloupe can be beneficial in managing electrolyte balance, it does not specifically address a potential adverse effect of the medication.

The nurse should first address the client pain level followed by the client's ECG results

Rationale

Pain level: Addressing the client's pain level is crucial because it directly affects their comfort and can be indicative of ongoing myocardial ischemia or infarction. The client initially reported chest pain as 7/10, which is significant. Although it has decreased to 5/10 after nitroglycerin, ongoing assessment of pain is essential to ensure it does not worsen or change in nature.

ECG results: The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes. These findings indicate acute myocardial ischemia or infarction, which is a critical concern. The ECG results guide further diagnosis and treatment decisions, such as determining the need for immediate reperfusion therapy (like thrombolytics or angioplasty).