A nurse is caring for a client who is receiving parenteral nutrition and identifies that the client has hypoglycemia. Which of the following actions should the nurse take?

B) Melena: Melena refers to black, tarry stools and is indicative of upper gastrointestinal bleeding. Warfarin is an anticoagulant medication that works by inhibiting the synthesis of vitamin K-dependent clotting factors, thereby prolonging the time it takes for blood to clot. While anticoagulation is intended to prevent thrombosis, it also increases the risk of bleeding, including gastrointestinal bleeding. Melena is a concerning sign of significant bleeding and requires prompt medical attention. The nurse should prioritize reporting melena to the provider to facilitate further evaluation and management, which may include adjusting the warfarin dosage or investigating the underlying cause of the bleeding.

A) Hair loss: Hair loss, or alopecia, is a known side effect of warfarin but is generally not considered a priority finding compared to signs of active bleeding. While hair loss can be distressing for clients, it is typically not life-threatening and may resolve spontaneously or with discontinuation of the medication.

C) Abdominal cramping: Abdominal cramping can occur for various reasons, including gastrointestinal upset or other gastrointestinal issues, but it is not typically associated with warfarin use. While the nurse should assess and address the client's abdominal cramping, it is not as urgent as reporting signs of active bleeding such as melena.

D) Fever: Fever may indicate the presence of an infection or inflammatory process but is not directly related to warfarin therapy. However, if the fever is accompanied by signs of bleeding or other concerning symptoms, it should be reported to the provider for further evaluation. Nonetheless, in the absence of other significant symptoms, fever alone may not be as urgent as reporting melena, which suggests active bleeding.

A) Monitor the client for seizure activity: While diazepam is an anticonvulsant medication and may be used to prevent or treat seizures, it is unlikely to cause seizure activity as an adverse reaction when administered for moderate sedation. However, if the client has a history of seizures or is at risk for seizures, monitoring for seizure activity is essential. In the context of moderate sedation, the primary concern is related to the sedative effects of diazepam rather than seizure activity.

B) Check the client's urinary output: Monitoring urinary out’ut is important for assessing renal function and fluid balance, but it is not directly related to assessing adverse reactions to diazepam. Adverse reactions to diazepam typically involve central nervous system depression, respiratory depression, or cardiovascular effects. Monitoring urinary output may be part of routine nursing care but is not specific to assessing adverse reactions to diazepam.

C) Monitor the client's oxygen saturation: This is the correct’action. Monitoring the client's oxygen saturation is essential for det’cting adverse reactions to diazepam, such as respiratory depression or hypoventilation. Diazepam can cause respiratory depression, especially when administered in higher doses or in combination with other sedative medications. Monitoring oxygen saturation allows the nurse to detect any signs of hypoxemia early and intervene promptly to ensure adequate oxygenation.

D) Auscultate the client's bowel sounds: While assessing bowel so’nds is important for evaluating gastrointestinal function, it is not directly related to assessing adverse reactions to diazepam. Adverse reactions to diazepam typically involve effects on the central nervous system and respiratory system rather than gastrointestinal function. Monitoring bowel sounds may be part of routine nursing assessment but is not specific to assessing adverse reactions to diazepam.