A client recovering in the intensive care unit following a percutaneous coronary intervention (PCI) and stent placement is receiving an IV infusion of tirofiban and has a compression device on the right inguinal PCI access site. When the client reports pain at the PCI access site, which action should the nurse take?

Choice A reason: Observing chest wall shape assesses for abnormalities like barrel chest, not tactile fremitus. Fremitus involves feeling vocal vibrations, increased in pneumonia due to consolidated lung tissue. Visual inspection does not evaluate vibration transmission, making it irrelevant for assessing fremitus in suspected pneumonia.

Choice B reason: Tactile fremitus is assessed by placing the palm on the chest while the client speaks, feeling vibrations through consolidated lung tissue in pneumonia. Fluid-filled alveoli enhance sound transmission, increasing fremitus. This directly evaluates lung pathology, confirming consolidation, critical for diagnosing pneumonia’s extent and severity.

Choice C reason: Using a stethoscope assesses breathing sounds like crackles, not tactile fremitus, which requires palpation of vocal vibrations. While breath sounds aid pneumonia diagnosis, fremitus specifically evaluates consolidation via vibration, making stethoscope use incorrect for this physical assessment technique focused on lung tissue density.

Choice D reason: Compressing tissue for crackling assesses crepitus or subcutaneous emphysema, not fremitus. In pneumonia, fremitus increases due to consolidation, not tissue compression. This method is irrelevant, as fremitus relies on vocal vibration transmission through palpation, making it inappropriate for assessing pneumonia-related lung changes.

Choice A reason: Facilitating a family meeting with palliative care discusses end-of-life goals in COPD, where airway obstruction causes respiratory failure. However, notifying the provider of the living will ensures immediate alignment with the client’s wishes, especially on ventilation, addressing the urgent need to respect legal directives in a critical scenario.

Choice B reason: Alerting staff about do-not-resuscitate (DNR) wishes assumes the living will specifies DNR, which requires confirmation. The provider must review the document first, as end-stage COPD necessitates clarity on ventilation preferences to guide urgent care, making notification the priority over premature staff alerts.

Choice C reason: Placing the living will in the EHR ensures documentation but does not immediately affect care. In end-stage COPD with respiratory distress, notifying the provider ensures the client’s wishes, like avoiding intubation, are followed promptly, preventing unwanted interventions, making this more urgent than administrative tasks.

Choice D reason: Notifying the provider of the living will is critical, as it legally specifies the client’s preferences, potentially refusing ventilation in end-stage COPD, where dyspnea results from irreversible obstruction. This ensures treatment respects autonomy, guiding immediate care to align with palliative goals, preventing inappropriate interventions during a crisis.