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.)

Correct answer: B

A. "The food is not great, but it is nice not having to do all of my own cooking.":

This statement acknowledges a minor issue with the food but overall expresses satisfaction with the convenience of not having to cook, indicating some level of acceptance of the transition.

B. "I don't want to go to the activity room because none of the other residents can hear."

This statement suggests a feeling of disconnection or dissatisfaction with the activities available in the assisted living facility. The client may be expressing frustration or a sense of isolation because the other residents cannot hear, which could hinder their ability to engage socially and participate in activities. Difficulty accepting the transition may manifest as resistance or reluctance to participate in aspects of facility life, such as group activities, due to perceived limitations or barriers.

C. "The staff sometimes have to remind me to use a cane when I walk in the hall.":

While this statement may indicate some adjustment to the need for assistance or reminders, it does not necessarily suggest difficulty accepting the transition. Instead, it reflects a willingness to comply with safety recommendations provided by the staff.

D. "When I go out, I've been using public transportation since I can't drive anymore":

This statement acknowledges a change in transportation habits due to inability to drive, which may be a practical adaptation to the client's circumstances rather than a sign of difficulty accepting the transition to assisted living.

A. Giving the client's medications between meals:

Administering medications between meals does not address the risk of aspiration associated with dysphagia. Moreover, timing of medication administration in relation to meals may vary depending on the specific medication requirements.

B. Assisting the client into semi-Fowler's position:

While positioning can play a role in facilitating swallowing, semi-Fowler's position alone may not be sufficient to address the risk of aspiration in clients with dysphagia. Moreover, simply positioning the client without considering other factors may not ensure safe medication administration.

C. Encouraging the client to use a straw to take the medication:

Using a straw might not be appropriate for clients with dysphagia as it can increase the risk of aspiration, especially if the client has difficulty controlling the flow of liquid or coordinating swallowing movements.

D. Administer the client's medications one at a time.

Dysphagia refers to difficulty in swallowing, which can increase the risk of choking or aspiration. Administering medications one at a time ensures that each pill is swallowed safely and reduces the risk of aspiration. It allows the nurse to closely monitor the client's ability to swallow each medication and intervene if necessary.