A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which of the following interventions should the nurse include?

Rationale:

A. Email the client's health information to the facility in an unencrypted file: Sending unencrypted emails violates HIPAA standards, as it risks unauthorized access to protected health information. All electronic transmissions must be secured to ensure client confidentiality.

B. Fax the client's name and identifiable information to the rehabilitation: Faxing identifiable information can be permissible if proper safeguards are used, but without assurance of security or a cover sheet, this could breach confidentiality. It’s not the best initial action without those protections.

C. Discuss the client's response to the transfer with another staff nurse: Unless the other nurse is directly involved in the client’s care, this discussion is unnecessary and breaches confidentiality. Health information should only be shared on a need-to-know basis.

D. Provide a verbal report of the client's condition to the paramedic: Providing a verbal handoff to the paramedic is appropriate and necessary for continuity of care during transfer. It is a secure, direct communication method that supports both confidentiality and patient safety.

Rationale for correct choices:

• Preeclampsia: The client presents with classic signs of preeclampsia, including elevated blood pressure (156/96 mm Hg), facial and dependent edema, hyperreflexia (DTR 3+), and right upper quadrant pain. Laboratory findings such as thrombocytopenia, elevated liver enzymes, and proteinuria also support this diagnosis.
• Urinalysis: Proteinuria is a key diagnostic criterion for preeclampsia, and this client’s urinalysis reveals protein levels (25 mg/dL) above normal limits, indicating kidney involvement and supporting the preeclampsia diagnosis.
• Pain assessment: Right upper quadrant pain is a significant symptom of preeclampsia, suggesting hepatic involvement such as liver capsule distension or possible HELLP syndrome. This pain, combined with other clinical and lab findings, signals severity and risk for maternal complications.

Rationale for incorrect choices:

• Chorioamnionitis: This infection is typically accompanied by fever, uterine tenderness, and foul-smelling discharge. The client is afebrile with clear lungs and no uterine tenderness, making chorioamnionitis unlikely.
• Preterm labor: No contractions or cervical changes were noted. The fetal heart rate is normal, and the client’s symptoms do not suggest imminent labor.
• Serum WBC count: The client’s WBC count is within normal limits, which does not support infection or inflammatory processes related to chorioamnionitis.
• Fundal assessment: Fundal height of 29 cm at 30 weeks is appropriate and shows no evidence of uterine enlargement or contraction indicative of preterm labor.
• Fetal monitor results: The fetal heart rate is 140/min and stable, showing no signs of distress that would suggest preterm labor or infection.
• Hemoglobin: Hemoglobin is within normal limits and does not contribute to the risk assessment for preeclampsia or infection.