A nurse is reinforcing teaching with an older adult client about preventing osteoporosis. Which of the following recommendations should the nurse make?

A. Obtain vital signs every 5 min.

Rationale: The client's vital signs indicate hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). Frequent monitoring of vital signs is essential to assess changes in the client's condition and guide further interventions.

E. Initiate a second peripheral IV.

Rationale: Given the client's low urine output (110 mL over 6 hours) and signs of possible hypovolemia or fluid imbalance, establishing an additional IV line can facilitate the administration of fluids and medications more effectively.

F. Apply oxygen.

Rationale: The client's oxygen saturation is slightly decreased at 96% on room air. Applying supplemental oxygen can help improve oxygenation and alleviate symptoms related to decreased oxygen levels.

Not Recommended Actions:

B. Place the client in high-Fowler's position: This position might not be appropriate for a client with chest pain and potential hypovolemia, as it could exacerbate hypotension.

C. Perform gastric lavage: The output from the nasogastric tube (800 mL sanguineous) does not indicate a need for gastric lavage unless there is a specific reason to suspect gastrointestinal bleeding that requires immediate intervention.

D. Prepare to administer anticoagulants: There is no indication of thromboembolism or need for anticoagulants based on the provided information. The focus should be on addressing hypotension and fluid imbalance.

A. "You should not have sexual intercourse while the monitor is in place.": This is incorrect because sexual activity is generally not restricted while wearing a Holter monitor. The main focus is on ensuring the monitor remains attached.
B. "You can bathe while wearing the electrodes.": This is incorrect because bathing or getting the electrodes wet can interfere with the monitor's functionality and potentially lead to inaccurate readings.
C. "You should remove the electrodes when you go to bed.": This is incorrect because the electrodes should remain in place for the full 24-hour period to ensure continuous monitoring.
D. "You will need to record daily activities in a diary.": This is correct as recording activities in a diary is crucial for correlating symptoms with the Holter monitor data.