A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

Rationale for correct choices:

• Administer oxygen at 2 L/min via nasal cannula: The client's oxygen saturation has dropped to 92% on room air, indicating mild hypoxia. Supplemental oxygen should be administered to improve myocardial oxygenation and reduce ischemia while further interventions are being prepared.
• Administer sublingual nitroglycerin: Nitroglycerin is a first-line medication for chest pain caused by suspected myocardial ischemia. It promotes vasodilation, reduces myocardial oxygen demand, and provides symptom relief. Administering it promptly can help prevent further cardiac damage.

Rationale for incorrect choices:

• Request a prescription for an increase in statin medication: Although the client has hyperlipidemia, increasing the statin dose is not an immediate priority during an acute chest pain episode. Lipid management is important long-term but does not address the acute ischemic event.
• Prepare the client for cardiac catheterization: Cardiac catheterization may eventually be necessary, but it is not the nurse’s first action. The priority is to stabilize the client’s symptoms (oxygenation and pain) before preparing for any invasive diagnostic or therapeutic procedure.
• Check a STAT cardiac troponin: Troponin has already been obtained and is within normal limits at this point. While serial troponins may be needed later, immediate nursing priorities focus on symptom relief and oxygenation rather than repeating the test right away.
• Request a prescription for a beta-blocker: Beta-blockers may be used in the treatment of suspected myocardial infarction to reduce heart rate and myocardial oxygen demand. However, their initiation typically follows pain relief, oxygenation, and diagnostic confirmation, not as the first nursing action.

Rationale:

A. Cheyne-Stokes respirations: This irregular breathing pattern is common in clients nearing end of life due to neurologic decline. It is not a direct indicator of pain and does not necessarily require pain medication unless associated with distress.

B. Restlessness: Restlessness in a palliative care client often signals unrelieved pain, discomfort, or anxiety. It is a nonverbal cue frequently observed in clients unable to communicate pain and should prompt consideration of analgesia.

C. Mottled skin: Mottling is a sign of reduced perfusion and impending death. It reflects circulatory changes but does not directly indicate pain or warrant pain medication unless accompanied by other signs of distress.

D. Constricted pupils: Pupil constriction may result from certain medications (e.g., opioids) or brainstem pressure but is not a reliable sign of pain. It does not, by itself, indicate a need for analgesic intervention.