A nurse is reviewing laboratory results for a client who has heart failure and notes a serum potassium level of 5.2 mEq/L (3.5 to 5.0 mEq/L). Which of the following medications should the nurse withheld?

A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.

B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.

C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.

D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.

A. Determine the client's Glasgow Coma Scale score: Assessing the client’s neurological status using the Glasgow Coma Scale (GCS) is the first action because it establishes a baseline for consciousness, guides priority interventions, and helps detect early deterioration. Rapid neurological assessment is critical in closed head injuries to identify life-threatening changes.

B. Prepare the client for an MRI of the brain: Imaging is important for diagnosis, but it is not the first action. The client’s neurological status must be assessed and stabilized before sending them for diagnostic procedures to ensure safety during transport and imaging.

C. Administer mannitol IV bolus to the client: Mannitol is used to reduce intracranial pressure, but administering it before assessing neurological status may not be indicated. Treatment should be guided by the assessment findings, including GCS and signs of increased intracranial pressure.

D. Insert an indwelling urinary catheter for the client: Catheterization may be necessary for monitoring output in critically ill clients, but it is not a priority over assessing neurological status. Maintaining airway, breathing, and circulation, and assessing neurologic function take precedence in head injury care.