The nurse plans to administer the adult client’s prescriptions which are metoprolol, hydrochlorothiazide, enoxaparin and atorvastatin.

The current laboratory values are; Serum potassium 5.2 mmol/L, Platelet Count 98,000/mm, Serum cholesterol 250 mg/dL and Serum Creatinine 1.2 mg/dL.
Which medication should the nurse hold and notify the prescriber?

This indicates that the client has a fluid volume deficit, which is consistent with the signs and symptoms of low urine output, weight gain, irritability, and headache. The normal range for serum osmolality is 275 to 295 mOsm/Kg.

Choice A is wrong because hemoglobin 15.3 mg/dL is within the normal range of 12 to 18 mg/dL and does not correlate with fluid imbalance.

Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy

treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.

According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).

Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.

Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.

Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.