The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

For Potential Conditions:

The correct answer is c) Abdominal compartment syndrome.

Choice A reason: Pneumothorax is a condition where air leaks into the pleural space, causing lung collapse and impaired gas exchange. It can cause respiratory distress, hypoxia, chest pain, and decreased breath sounds on the affected side. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice B reason: Pulmonary embolism is a condition where a blood clot blocks one or more pulmonary arteries, causing impaired gas exchange and reduced blood flow to the lungs. It can cause respiratory distress, hypoxia, chest pain, and tachycardia. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice C reason: Abdominal compartment syndrome is a condition where increased intra-abdominal pressure causes reduced blood flow to the abdominal organs and impaired diaphragm movement. It can cause respiratory distress, hypoxia, abdominal distension, acidosis, decreased urine output, and organ failure. It is a common complication of cirrhosis with ascites.

Choice D reason: Sepsis is a condition where a systemic inflammatory response to an infection causes organ dysfunction and hypoperfusion. It can cause respiratory distress, hypoxia, fever or hypothermia, tachycardia, acidosis, and hyperglycemia. However, it does not cause abdominal distension unless there is an intra-abdominal infection.

The two actions the nurse should take to address abdominal compartment syndrome are:

• Prepare the client for a paracentesis: Paracentesis is a procedure where a needle or catheter is inserted into the peritoneal cavity to drain excess fluid and reduce intra-abdominal pressure.
• Place an intravenous line to start fluid boluses: Fluid boluses are given to maintain adequate blood pressure and perfusion to the vital organs.

The two parameters the nurse should monitor to assess the client’s progress are:

• Oxygen saturation: Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood. It should be maintained above 90% to ensure adequate oxygen delivery to the tissues.
• Urine output: Urine output reflects the function of the kidneys and the perfusion of the renal arteries. It should be maintained above 0.5 mL/kg/hour to prevent acute kidney injury and electrolyte imbalances.

The client has inhaled smoke, which can cause respiratory problemssuch as airway obstruction, bronchospasm, and pulmonary edema. The client also has initial fluid shifts, which can lead to electrolyte imbalancesuch as hyponatremia, hyperkalemia, and metabolic acidosis.

Choice A: inhaled smoke - respiratory problems

This is a correct choice. Inhaled smoke can damage the respiratory system by causing inflammation, edema, and carbon monoxide poisoning.

Choice B: initial fluid shifts - electrolyte imbalance

This is a correct choice. Initial fluid shifts occur when fluid moves from the intravascular space to the interstitial space due to increased capillary permeability. This can result in electrolyte imbalance such as low sodium, high potassium, and low bicarbonate levels.

Choice C: increased cardiac output - high blood sodium levels

This is an incorrect choice. Increased cardiac output is not a condition that occurs in burn patients. High blood sodium levels are not a common finding in burn patients either. High blood sodium levels can occur due to dehydration or excessive sodium intake.

Choice D: decreased catecholamines - hypometabolism

This is an incorrect choice. Decreased catecholamines are not a finding in burn patients. Catecholamines are hormones that increase heart rate, blood pressure, and metabolism in response to stress. Burn patients have increased catecholamines due to pain and tissue injury. Hypometabolism is also not a condition that occurs in burn patients. Hypometabolism is a state of low metabolic rate that can occur due to starvation, hypothyroidism, or hypothermia. Burn patients have increased metabolism due to increased energy demands for wound healing and thermoregulation.