The nurse in the intensive care unit is caring for a client with left-sided heart failure and pulmonary edema as a complication.

The nurse identifies a nursing diagnosis of impaired gas exchange related to fluid in the alveoli.

Which of the following interventions would be considered the least priority according to the nursing diagnosis?

Choice A rationale
Calcium channel blockers are primarily used to treat hypertension, angina, and certain heart arrhythmias. They work by relaxing the muscles of your heart and blood vessels. While they can affect heart rate and blood pressure, they would not typically have immediate implications for a patient presenting with intermittent chest pain.
Choice B rationale
Phosphodiesterase 5 enzyme inhibitors, such as sildenafil (Viagra), are used to treat erectile dysfunction and pulmonary arterial hypertension. These medications can interact with nitroglycerin, a common medication used to treat chest pain, to cause a severe and life-threatening drop in blood pressure. Therefore, it’s crucial to know if a patient is taking this type of medication when they present with chest pain.
Choice C rationale
Anticoagulants are used to prevent blood clots. If a patient is taking an anticoagulant, it could affect their clotting times and could be important if the patient needs surgery or if the cause of their chest pain is a clot. However, this would not typically have immediate implications for the treatment of chest pain.
Choice D rationale
Loop diuretics are strong diuretics that are used to treat edema and hypertension. They work by preventing your body from absorbing too much salt, allowing the salt to instead be passed in your urine. While important to know for overall patient care, they would not typically have immediate implications for a patient presenting with chest pain.

Choice A rationale
The need for Metoprolol (Lopresor) STAT does not necessarily indicate progression to septic shock. Metoprolol is a beta-blocker used to treat high blood pressure, heart failure, and angina. While it may be used in the management of sepsis to control heart rate, its use does not specifically indicate progression to septic shock.
Choice B rationale
The need for Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement is a strong indicator of septic shock. Norepinephrine is a vasopressor, a type of medication used to increase blood pressure. In septic shock, vasopressors are often required to maintain adequate blood pressure and organ perfusion despite aggressive fluid resuscitation.
Choice C rationale
A serum lactate level less than 2 mmol/L is generally not indicative of septic shock. Elevated lactate levels can indicate tissue hypoperfusion, a condition that may occur in septic shock. However, a level less than 2 mmol/L is typically considered within the normal range.
Choice D rationale
A blood pressure of 70/34 after the fluid bolus could indicate progression to septic shock. In septic shock, despite aggressive fluid resuscitation, blood pressure often remains dangerously low, which can lead to inadequate blood flow to the organs.