After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Choice A reason: Taking two more readings confirms elevated BP, as a single reading may reflect technique errors or transient factors like pain, which increase sympathetic activity and vasoconstriction. Multiple readings ensure accuracy, critical for diagnosing hypertension and guiding intervention to prevent cardiovascular complications like stroke.

Choice B reason: Assigning a UAP to recheck BP in an hour delays assessment of potentially dangerous hypertension, which risks acute complications like myocardial ischemia. Immediate confirmation is needed, as elevated BP from norepinephrine release increases vascular resistance, making delayed rechecking inappropriate for urgent evaluation.

Choice C reason: Retaking BP in the opposite arm verifies accuracy, as differences may indicate arterial occlusion. Elevated BP increases catecholamine-driven vascular resistance. Measuring both arms rules out localized issues, ensuring reliable data to guide management of hypertension, critical to prevent end-organ damage like renal failure.

Choice D reason: Assessing apical-radial pulse deficit is relevant for atrial fibrillation, not directly for elevated BP. Hypertension results from increased vascular resistance, not pulse discrepancies. Confirming BP and assessing context are more immediate to determine urgency, making this less relevant than verifying readings or identifying triggers.

Choice E reason: Determining activity and feelings identifies transient BP elevation causes, like stress or exercise, which raise norepinephrine, increasing heart rate and vascular tone. This contextualizes the reading, differentiating situational from chronic hypertension, ensuring appropriate intervention to manage cardiovascular risk and guide further assessment.

Choice A reason: Discouraging straining on stool prevents pain exacerbation or constipation in cancer but is not the priority with a pain score of 9. Severe pain from bone metastases, stimulating nociceptors, requires urgent IV narcotics to improve comfort, addressing the primary palliative goal over secondary issues like straining.

Choice B reason: A pain score of 9 in metastatic bone cancer indicates severe nociceptive pain from tumor invasion. IV narcotics (e.g., morphine) rapidly bind opioid receptors, reducing pain perception. This prioritizes comfort in palliative care, especially with stable vitals (SpO₂ 95%), addressing pain before nausea in this critical scenario.

Choice C reason: An IV fluid bolus treats dehydration from vomiting but does not address severe pain (9/10), a palliative priority. Bone metastases cause intense pain, requiring narcotics. Fluids are secondary, as vitals (BP 110/80) suggest stability, making pain relief more urgent to enhance quality of life in palliative care.

Choice D reason: An IV antiemetic controls nausea, likely from tumor or treatment effects, but severe pain (9/10) is the priority in palliative care. Narcotics provide rapid relief for bone metastasis pain, improving comfort. Antiemetics are secondary, as pain significantly impacts quality of life more immediately than nausea.