The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer.
The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

Measuring oxygen saturation is not directly relevant to the administration of vancomycin or the monitoring of its potential side effects. While oxygen saturation is important to assess in patients with respiratory concerns, it does not provide information about kidney function, which is essential for safe vancomycin use.

Choice B rationale:

Auscultating bowel sounds, while a part of general abdominal assessment, is not the most crucial action before administering vancomycin. Vancomycin is not known to have significant effects on bowel motility, and its primary concern is nephrotoxicity.

Choice C rationale:

Assessing body temperature can be helpful in evaluating for infection, but it is not the most specific or sensitive indicator of vancomycin-related adverse effects. Fever can be a sign of various conditions, and it does not directly assess kidney function.

Choice D rationale:

Checking serum creatinine is the most essential action before administering vancomycin because it allows for assessment of kidney function. Vancomycin is primarily excreted by the kidneys, and impaired renal function can lead to elevated drug levels and increased risk of nephrotoxicity. By checking serum creatinine, the nurse can ensure that the patient's kidney function is adequate to safely excrete vancomycin and can adjust the dosage or frequency of administration if necessary.

Choice A rationale:

Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.

While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.

Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.

Choice C rationale:

Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.

It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:

Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.

Choice B rationale:

Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.

Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.

Are comfortable for the patient and can be left in place for several days.