A nurse is assisting with the care of a client.

Exhibits

Complete the following sentence by using the list of options.

After notifying the provider, the nurse should first

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and then

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A. Sputum characteristics. The presence of blood-tinged sputum raises concern for tuberculosis (TB) or another serious pulmonary condition, requiring further evaluation. Hemoptysis can indicate active infection or cavitary lung disease.
B. Respiratory complaint. The client reports a persistent, productive cough, night sweats, and fatigue, which are hallmark symptoms of TB. These symptoms, combined with recent travel to a TB-endemic region, increase the likelihood of infection and warrant further assessment.
C. Blood pressure. The client’s blood pressure is within the normal range and does not indicate an immediate concern requiring further evaluation.
D. Heart rate. A heart rate of 98/min is elevated but still within an acceptable range for mild illness or fever. While tachycardia can be associated with infection, it is not the most critical finding requiring urgent follow-up.
E. Temperature. A temperature of 38.1°C (100.5°F) indicates a low-grade fever, which is a common sign of TB or other infections. Given the client's symptoms and history, this finding warrants further investigation.
F. Travel history. The client recently traveled to South Africa, a region with a high prevalence of TB. Travel history is a crucial factor in determining TB risk and must be considered in the diagnostic process.
G. Oxygen saturation. The client’s oxygen saturation is 98% on room air, which is within normal limits and does not require further evaluation at this time.

A. "Your health care surrogate will make decisions on your behalf if you are unable." A health care surrogate, also known as a durable power of attorney for health care, is a person designated to make medical decisions when the client is unable to do so. This ensures that the client’s wishes are respected in situations where they cannot communicate or make informed choices.
B. "Once you have completed a living will, it cannot be changed." A living will can be revised or revoked at any time as long as the client is mentally competent. Changes may be necessary due to evolving personal beliefs, medical advancements, or changes in health status.
C. "You should appoint a family member as your health care surrogate." While a family member can be chosen, it is not a requirement. The client has the right to appoint anyone they trust to make medical decisions, including a close friend or legal representative, as long as they meet the legal criteria in their state or country.
D. "You will need an attorney to appoint a health care surrogate." An attorney is not required to appoint a health care surrogate. Most states provide standardized forms that can be completed and signed by the client in the presence of witnesses or a notary, depending on local legal requirements.