A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

C. Clients with this score may have altered consciousness and require close monitoring for changes in neurological status, respiratory function, and other complications. Placing this client closest to the nurses' station allows for prompt assessment and intervention if there is deterioration or emergent need.

A Clients with a score of 0 are generally stable and may not require immediate or intensive monitoring. Therefore, this client may not need to be placed closest to the nurses' station unless there are other medical considerations.

B. A grade 1 concussion is considered mild, and while the client may have symptoms such as headache, they are typically stable with minimal risk of deterioration. Monitoring for worsening symptoms is important, but this client may not require immediate proximity to the nurses' station unless symptoms worsen unexpectedly.

D. Clients who are brain dead and awaiting organ procurement are typically stable in terms of neurological status as they are no longer responsive. This client may not necessarily need to be closest to the nurses' station unless specific care needs arise.

Metoprolol 5 mg every 2 to 3 min up to three doses

Nonessential: Metoprolol is a beta-blocker used to reduce heart rate and blood pressure. However, in this scenario, the client already has a history of irregular heart rate and is currently tachycardic. Starting metoprolol at this frequency and dose without knowing the client's response or stability could exacerbate their condition. Therefore, it is considered nonessential until further assessment and stabilization.

Oxygen at 2 L/min via nasal cannula

Anticipated: The client's oxygen saturation dropped to 89% at 1015 and improved to 92% with oxygen supplementation by 1200. Given the client's symptoms and fluctuating oxygen saturation, supplemental oxygen is necessary to ensure adequate tissue oxygenation and is anticipated to support respiratory function.

Draw electrolytes along with Hgb and Hct

Nonessential: While electrolyte levels (such as potassium) are important to monitor, they are not immediately critical in the management of acute myocardial infarction or unstable angina. They can be drawn later for comprehensive assessment but are not urgently needed in the acute phase of care.

Morphine 6 mg IV bolus every 3 hr as needed for pain

Anticipated: Morphine is indicated for managing severe pain, such as chest pain associated with myocardial infarction. The client reported significant chest pain (7/10 initially), and morphine is appropriate to alleviate discomfort and reduce myocardial oxygen demand.

Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses

Anticipated: Nitroglycerin is a vasodilator that helps relieve chest pain associated with angina or myocardial infarction by dilating coronary arteries. Given the client's chest pain and the protocol for administering nitroglycerin, it is anticipated to be effective in managing symptoms and improving coronary blood flow.

Obtain daily weight

Nonessential: Daily weight monitoring is useful for assessing fluid status in some conditions, but it is not immediately necessary in the acute management of myocardial infarction or unstable angina unless there are signs of fluid overload or heart failure, which are not evident in this case.

Atropine 0.5 mg IV bolus every 5 min up to 2 mg

Contraindicated: Atropine is used to treat bradycardia (slow heart rate). However, the client in this scenario is tachycardic (rapid heart rate), and atropine would exacerbate this condition. Therefore, it is contraindicated and should not be administered.