A nurse is caring for a client who has osteoporosis and a new prescription for alendronate. Which of the following should the nurse assess prior to initiating therapy?

The nurse should first address the client’s oxygen saturation, followed by the client’s blood pressure.

Addressing the oxygen saturation is crucial because the client’s level has dropped significantly to 86%, indicating potential respiratory distress or hypoxia. Following that, the nurse should address the blood pressure, which has also dropped, indicating possible hemodynamic instability.

Let’s break down the case notes to understand why addressing the client’s oxygen saturation and blood pressure is critical:

Oxygen Saturation

• Initial Vital Signs (1200): The client’s oxygen saturation was 100% on 2 L oxygen via nasal cannula.
• Current Vital Signs (1220): The oxygen saturation has dropped to 86% on the same oxygen support.

This significant drop in oxygen saturation indicates that the client is not receiving adequate oxygen, which can lead to hypoxia. Hypoxia can cause severe complications, including organ damage. Therefore, improving oxygenation is the top priority.

Blood Pressure

• Initial Vital Signs (1200): The client’s blood pressure was 110/75 mm Hg.
• Current Vital Signs (1220): The blood pressure has decreased to 90/60 mm Hg.

The drop in blood pressure suggests that the client is experiencing hemodynamic instability, which could be due to several factors, including dehydration, blood loss, or a reaction to anesthesia. Low blood pressure can lead to inadequate perfusion of vital organs, which is why it needs to be addressed promptly after stabilizing the oxygen saturation.

Other Symptoms

• Muscle Rigidity: The client is experiencing painful muscle rigidity, which could be a sign of a serious condition like malignant hyperthermia, especially given the elevated temperature.
• Temperature: The client’s temperature has spiked to 40.2°C (104.4°F), indicating a possible infection or reaction.
• Heart Rate: The heart rate has increased to 125/min, which could be a compensatory response to low blood pressure and hypoxia.
• Nausea and Vomiting: The client has vomited twice, which could contribute to dehydration and electrolyte imbalance.

Conclusion

By addressing the oxygen saturation first, the nurse ensures that the client is receiving adequate oxygen, which is essential for all bodily functions. Following that, stabilizing the blood pressure is crucial to ensure proper perfusion and prevent further complications.

Choice A rationale
Immediate-release exenatide pens should be discarded 30 days after the first use, not two months. This ensures the medication remains effective and free from contamination.
Choice B rationale
Exenatide is administered subcutaneously, not intramuscularly. The preferred injection sites are the abdomen, thigh, or upper arm.
Choice C rationale
Open exenatide pens should be stored at room temperature, but this is not the most critical aspect of patient education. Proper storage ensures the medication’s stability and effectiveness.
Choice D rationale
Immediate-release exenatide should be taken one hour before morning and evening meals to optimize its glucose-lowering effects by enhancing insulin secretion in response to meals.