A nurse is planning care for a client during Ramadan who is a devout Muslim. Which of the following actions should the nurse include regarding the client's diet?

Rationale:

A. Check the compatibility of cefazolin with the client's existing IV fluids: Compatibility is important to prevent precipitation or inactivation of the drug, but it should be done only after confirming the medication is safe for the client to receive.

B. Assess the IV for patency: Ensuring the IV line is patent is necessary before administration to avoid infiltration or extravasation, but it is not the first priority when preparing a first-time antibiotic dose.

C. Review the client's allergy history: Reviewing allergies is the first and most critical step, as cefazolin is a cephalosporin that can cause severe allergic reactions, particularly in clients with a history of beta-lactam (e.g., penicillin) allergy. Administering the drug without this check could cause life-threatening anaphylaxis.

D. Obtain the reconstituted antibiotic from the pharmacy: Securing the medication from the pharmacy is part of preparation, but this should only occur after confirming it is safe for the client to receive based on allergy status.

Rationale for correct choices:

• Blood pressure: The client’s blood pressure is 90/50 mm Hg, indicating hypotension. This can signal volume depletion or active bleeding, which requires immediate assessment and intervention to prevent shock or organ hypoperfusion.
• Hemoglobin and hematocrit: Hemoglobin of 9.1 g/dL and hematocrit of 27% indicate significant anemia, likely from gastrointestinal blood loss. Immediate follow-up is necessary to determine the source and provide interventions such as fluid resuscitation or transfusion.
• Heart rate: The client’s heart rate is 118/min, demonstrating tachycardia. This may be compensatory for hypotension or blood loss, suggesting hemodynamic instability and requiring prompt monitoring and intervention.
• Stool results: Positive hemoccult indicates gastrointestinal bleeding, which aligns with anemia and tachycardia. Identifying and managing the bleeding source is a priority to prevent further complications.
• Current medication: The client takes high-dose ibuprofen (800 mg three times daily), a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs increase the risk for peptic ulcer disease and gastrointestinal bleeding, contributing to the client’s current presentation and requiring immediate provider notification.

Rationale for incorrect choices:

• Temperature: The client’s temperature is 37.5° C (99.5° F), slightly elevated but not indicative of infection or immediate risk. Monitoring is appropriate but not urgent.
• WBC count: WBC is 6,700/mm³, within normal limits, indicating no current infection or acute inflammatory response. This does not require immediate follow-up.
• Respiratory rate: Respiratory rate is 18/min, within normal limits for an adult, and does not indicate acute respiratory distress. Immediate intervention is not necessary.