A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

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.

C. Muscle twitching post-thyroidectomy can indicate hypocalcemia, a common complication due to inadvertent damage or removal of the parathyroid glands during surgery. Hypocalcemia can lead to neuromuscular irritability, including muscle twitching, tingling, or tetany.

A Nausea is a common postoperative symptom and can be caused by anesthesia, pain medications, or changes in gastrointestinal function. While uncomfortable, nausea alone is typically not an urgent concern

B Serosanguineous drainage (thin, pink-tinged fluid) from the surgical incision is expected in the early postoperative period. It indicates normal wound healing and does not usually require urgent attention

D. Routine incisional pain does not typically require urgent reporting unless accompanied by other concerning symptoms.