A nurse is preparing a client's medications.
Which of the following actions should the nurse take in following legal practice guidelines? (Select all that apply.)

Condition: Post-operative pain.

2 actions:

Administer acetaminophen (Tylenol) for mild pain,

Apply a warm compress to the surgical site.

2 parameters:

Pain level on a 0-10 scale,

Surgical site appearance.

Rationale for correct condition: Post-operative pain is expected after surgery and the client reports mild pain (2 out of 10). Managing pain is crucial for recovery and mobility. Mild pain indicates the need for non-opioid analgesics. Pain management enhances comfort and healing. Addressing pain prevents complications.

Rationale for actions: Administering acetaminophen targets mild pain effectively. It is appropriate for the reported pain level. Warm compresses can soothe soreness and reduce pain without medication. Encourages blood flow and healing. Encouraging ambulation prevents DVT but is not pain-focused. Monitoring for infection is important but not the priority for mild pain. Ondansetron treats nausea, not pain.

Rationale for parameters: Pain level on a 0-10 scale assesses pain management effectiveness. Monitoring pain ensures appropriate interventions. Surgical site appearance checks for complications affecting pain, like infection. Respiratory rate is stable and less relevant. Oxygen saturation is normal, unrelated to pain. Urine output monitors hydration, not pain.

Rationale for incorrect conditions: Post-operative nausea and vomiting is not reported. Surgical site infection would show signs like redness or fever. DVT focuses on circulation, not pain.

Choice A rationale: Furosemide is a loop diuretic used to reduce fluid overload in CHF patients. However, it can exacerbate electrolyte imbalances, particularly hypokalemia. Since the client is already experiencing muscle spasms and has low calcium levels, additional diuretic therapy could worsen these symptoms.

Choice B rationale: Metoprolol is a beta-blocker used to manage hypertension and heart rate in CHF patients. While beneficial for blood pressure control, it does not address the immediate issue of muscle spasms and constipation the client is experiencing.

Choice C rationale: Potassium chloride is indicated to address potential hypokalemia, which may be causing the client's muscle spasms. CHF patients on diuretics often experience low potassium levels, so supplementation is crucial to prevent complications and alleviate symptoms.

Choice D rationale: Acetaminophen is an analgesic and antipyretic, useful for pain and fever management. However, it does not address the client's reported muscle spasms, which are likely related to electrolyte imbalances.