The nurse has reviewed the Diagnostic Results from Day 1 at 2245.

The nurse is contributing to the plan of care for the client. Which of the following interventions should the nurse include?

For each potential intervention, click to specify if the intervention is anticipated or not anticipated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

• Assist with IV bolus of morphine as needed: The client is experiencing severe right upper quadrant pain radiating to the back with a pain score of 8/10. Morphine is commonly used to manage acute pain in cholelithiasis or biliary colic, providing comfort while minimizing patient distress during assessment and treatment.

• Hold the client's blood pressure medication: There is no immediate indication to hold antihypertensive medication; the client’s blood pressure is mildly elevated, and management of hypertension should continue unless otherwise directed by the provider.

• Prepare the client for a lumbar puncture: A lumbar puncture is not relevant for cholelithiasis or biliary symptoms. It is indicated for neurological conditions such as suspected meningitis or subarachnoid hemorrhage, which are not present in this client.

• Obtain a blood culture: Blood cultures are not routinely indicated for cholelithiasis unless there is suspicion of sepsis or cholangitis. The client’s fever is mild, and there is no current evidence of systemic infection requiring cultures.

• Place the client on NPO status: Clients with cholelithiasis often require NPO status in preparation for potential surgical intervention, such as cholecystectomy, and to reduce stimulation of the gallbladder and further biliary pain or vomiting. This also prevents aspiration risk if surgery is necessary.

• Initiate continuous intravenous fluids: Continuous IV fluids are important to maintain hydration, especially since the client has vomiting and inadequate oral intake. IV fluids help correct fluid losses, support electrolyte balance, and maintain hemodynamic stability during acute illness.

• Assist with antiemetic IV bolus as needed: The client has persistent nausea and vomiting with bile. Antiemetics help manage discomfort, prevent dehydration, and allow tolerance of treatment while improving overall patient stability.