The client is a very thin, emaciated 86-year-old woman who ...

[09madisonrousseau09]

The client is a very thin, emaciated 86-year-old woman who reports new-onset shortness of breath. Chest x-ray reveals a spot on the lungs that the physician believes is an inoperable lung cancer.
 
  The client's emaciated status would exclude her from receiving chemotherapy, and the physician says the location of the cancer would make radiation therapy unsuccessful. In advocating for this client, the nurse would encourage the health care team to: 1. Perform any procedure necessary to diagnose this suspected cancer.
  2. Promote the use of noninvasive procedures to diagnose the suspected cancer.
  3. Provide palliative care to treat the signs and symptoms without diagnostic testing.
  4. Determine the client and family's wishes regarding diagnostic testing.

Question 2

The nurse assisting with the care of a client receiving two units of blood is asked to record vital signs after the second unit is initiated.
 
  The nurse enters the room of the client, a 28-year-old female admitted following a salpingectomy secondary to an ectopic pregnancy, and finds her unconscious with weak pulse and shallow respirations. The nurse notes a rash over the exposed areas of her body. What is the nurse's priority action? 1. Attempt to revive the woman and measure vital signs.
  2. Increase the rate of the blood infusion to raise her blood pressure quickly.
  3. Stop the blood infusion.
  4. Prepare another IV with fresh tubing, and connect to the IV site where the blood was infusing.

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Answer to Question 1

4
Rationale: An elderly emaciated client with few options for treatment of cancer if confirmed can be best treated palliatively, but it is the choice of the client and family that should direct the plan of care and choices of diagnostic testing.

Answer to Question 2

3
Rationale: The client is most likely having a blood transfusion reaction, and the priority intervention, before doing anything else, is to make sure that the client does not receive any more blood. After the infusion is stopped, the RN should be notified, vital signs should be recorded, and new IV solution should be hung using fresh tubing, but the first and most important priority is to stop infusing the blood that is causing the reaction.

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