A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A. Corneas with an opaque appearance:

An opaque appearance of the corneas indicates an abnormal finding and could suggest a pathological condition such as corneal edema, scarring, or infection. The corneas should normally be clear and transparent to allow light to pass through to the retina.

B. Pupils that are 8 to 9 mm in diameter:

Pupils that are 8 to 9 mm in diameter are abnormally large and dilated. Normal pupil size varies between approximately 2 to 4 mm in diameter under normal lighting conditions. An 8 to 9 mm diameter suggests mydriasis, which may be caused by various factors such as medications, neurological conditions, or trauma.

C. Eyelashes that curl slightly outward.

Eyelashes that curl slightly outward are a normal finding and help to protect the eyes by preventing foreign particles from entering. This finding is considered within the range of normal anatomy and physiology of the eye.

D. Eyelids that blink involuntarily 30 to 35 times per minute:

While blinking is a normal physiological response that helps to keep the surface of the eye moist and clear debris, the rate of involuntary blinking typically ranges from 15 to 20 times per minute in adults, not 30 to 35 times per minute. A higher rate of blinking could indicate irritation, dryness, or other ocular discomfort.

A. "Enjoy the time you have and do the things you want to do":

While this response may seem supportive, it does not address the client's expressed desire for aggressive treatment. It is important for the nurse to acknowledge the client's wishes and provide appropriate support and information to help them make decisions about their care.

B. "Hospice care is the best thing for you at this time":

While hospice care may be appropriate for some clients with terminal illnesses, it is not appropriate to assume that it is the best option for every client. The nurse should not impose their own beliefs or preferences onto the client and should instead support the client in exploring their options and making decisions based on their individual needs and preferences.

C. "You need to understand that you have very little time left":

This response may be seen as dismissive or insensitive to the client's wishes for aggressive treatment. It does not acknowledge the client's autonomy or right to make decisions about their own care. The nurse should approach the situation with empathy and respect for the client's wishes, while also providing support and information to help them make informed decisions.

D. "I will contact your provider to discuss your options."

The client has expressed a desire for aggressive treatment, and it is important for the nurse to respect the client's autonomy and preferences. By stating that they will contact the provider to discuss the client's options, the nurse ensures that the client's wishes are communicated effectively and that they receive appropriate information and support to make informed decisions about their care.