Exhibits

The nurse is obtaining the client's vital signs prior to an endoscopy.

Complete the following sentence by using the list of options.

The nurse should first anticipate the need to

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then

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A. A licensed practical nurse (LPN) is capable of performing sterile dressing changes, which is within their scope of practice.
B. An admission assessment requires a registered nurse (RN) to evaluate and formulate a comprehensive care plan, which exceeds the scope of an LPN.
C. Discharge teaching requires the RN’s expertise to provide in-depth education and ensure the patient understands the plan.
D. Completing the Glasgow Coma Scale requires an RN to assess neurological status and make appropriate decisions about care.

A. Breath sounds
The presence of crackles at the bases of the lungs indicates possible pulmonary congestion or fluid accumulation in the lungs. This could be a sign of pulmonary edema, which may be due to chemotherapy-related side effects such as cardiotoxicity, or other complications like infection (e.g., pneumonia). Given the client's history of chemotherapy, this finding requires follow-up, as it could indicate a serious condition that needs to be addressed promptly.
B. Potassium level
: The client's potassium level is within normal limits (3.5 to 5 mEq/L). Although some chemotherapy drugs may affect electrolyte balance, this potassium level is not concerning at this time.
C. Blood pressure
This blood pressure is within normal limits, as the typical range for adult blood pressure is generally around 120/80 mm Hg. The reading does not indicate hypotension or hypertension, which would be concerning in the context of chemotherapy, which can affect blood pressure.
D. WBC count
A WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3, indicating leukopenia or a decreased immune response. This is a common side effect of chemotherapy, which suppresses bone marrow function, leading to lower white blood cell counts. This finding could increase the risk of infection and should be followed up to ensure the patient does not develop an infection, as the lower WBC count could compromise their ability to fight infections.
E. Temperature
A fever of 38.6°C (101.5°F) is significant and suggests the presence of infection, which is especially concerning in a patient with leukopenia due to chemotherapy. A fever in a chemotherapy patient is a medical emergency because of the risk of serious infections like neutropenic fever. This requires immediate follow-up and potentially further diagnostic tests, including blood cultures and a review of the patient's clinical status.