A nurse is collecting data from a client who has hyperparathyroidism and is receiving 0.9% sodium chloride via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Rationale:

A. 2+ pitting edema of the lower extremities: Mild to moderate lower extremity edema is common in pregnancy and often seen in preeclampsia. While it should be monitored, it is not an immediate danger unless accompanied by other severe symptoms.

B. Increased hemoglobin: Hemoconcentration may occur in preeclampsia due to fluid shifting into interstitial spaces, but a mildly elevated hemoglobin alone does not warrant urgent intervention. It should be evaluated in the context of other lab and clinical findings.

C. Blood pressure 158/54 mm Hg: Although the systolic pressure is elevated, it does not meet the threshold of severe hypertension (>160 systolic or >110 diastolic). This finding warrants monitoring and documentation but is not the most urgent among the listed options.

D. Client report of upper right quadrant pain: Right upper quadrant or epigastric pain can signal liver involvement in severe preeclampsia, potentially indicating HELLP syndrome. This is a critical warning sign and requires immediate attention to prevent complications such as liver rupture or seizure.

Rationale:

A. Consult with a pharmacist about the medication: Consulting a pharmacist is the most appropriate action when a nurse is unfamiliar with a medication. Pharmacists are knowledgeable about drug indications, dosages, side effects, and interactions, making them a key resource for medication safety.

B. Ask the client about the medication: Clients may have some knowledge about their prescriptions, but they are not reliable sources for professional clinical decisions. Relying on client input when the nurse lacks knowledge could lead to unsafe medication administration.

C. Ask the charge nurse to administer the medication: Delegating the task does not resolve the knowledge gap. The nurse remains responsible for ensuring they understand any medication they are preparing, and should take steps to educate themselves rather than pass the task to another nurse.

D. Complete an incident report: An incident report is only warranted if a medication error or adverse event occurs. Being unfamiliar with a drug and seeking clarification is a preventive measure, not an incident requiring formal reporting.