Patient Data Exhibits Which nursing action(s) is/are appropriate for the client at this time? Select all that apply.

A. Administer nausea medication: The client reports nausea and poor oral intake, which can worsen electrolyte imbalances and dehydration. Administering antiemetics as ordered helps improve comfort and prevents further complications. B. Draw potassium level STAT: The client has hyperkalemia (K⁺ 5.9 mEq/L) and new ECG changes. Rechecking potassium urgently is essential to confirm severity and guide immediate treatment. C. Perform a 12-lead electrocardiogram (ECG) STAT: Hyperkalemia can cause life-threatening arrhythmias, and the client’s telemetry already shows PVCs and tall T waves. A 12-lead ECG provides a comprehensive assessment for urgent intervention. D. Request for more frequent blood glucose: While the client’s glucose is slightly low (72 mg/dL), frequent monitoring may be useful but is not the most urgent priority compared to life-threatening hyperkalemia and cardiac risks. E. Administer calcium gluconate STAT: Calcium gluconate stabilizes cardiac membranes in hyperkalemia and is a critical intervention to prevent potentially fatal arrhythmias. Immediate administration is warranted. F. Clarify order of lisinopril with the healthcare provider: Lisinopril can increase potassium levels, which may worsen hyperkalemia. Clarifying the continuation or adjustment of this medication is essential to prevent further complications. G. Call the healthcare provider to notify changes in vital signs: The client’s blood pressure dropped to 96/88 mm Hg and heart rate increased to 125 bpm. These changes could indicate fluid imbalance, sepsis, or worsening renal function, requiring prompt provider notification. H. Perform a focused cardiovascular assessment: Hyperkalemia and the client’s telemetry changes necessitate careful cardiovascular assessment, including pulse quality, heart sounds, and rhythm to detect early signs of deterioration. I. Check blood glucose level STAT: The client’s glucose is slightly below normal, and with poor oral intake and insulin use, hypoglycemia is a concern. Checking blood glucose STAT ensures safe management. J. Teach client to take slow and deep breaths: While deep breathing can support oxygenation, it is not a priority intervention at this time. The client’s immediate risks involve hyperkalemia, cardiac instability, and electrolyte imbalances.