A hospice nurse is caring for a client.
Nurses' Notes
Vital Signs
Day 1 1000: Client lethargic, nods head to indicate pain. Extremities cool to touch, pallor noted. Breath sounds labored, irregular, scattered rhonchi heard throughout.
Day 2 1000: Client nonresponsive to verbal stimuli; moaning with grimacing when repositioning; mottling to lower extremities. Breath sounds with audible rhonchi, irregular, tachypnea, bladder incontinency.
Vital Signs
Day 1 1000: Temperature 38.5°C (101.3°F).
Blood pressure 78/46 mm Hg
Heart rate 112/min
Respiratory rate 26/min, irregular SaO2 85% on O2 at 2 L/min via face mask with 40% humidified air
Day 2 1000: Temperature 38.6°C (101.5°F)
Blood pressure 68/42 mm Hg
Heart rate 91/min
Respiratory rate 32/min, irregular SaO2 85% on O2 at 2L/min via face mask with 40% humidified air.
Which of the following actions should the nurse plan to take?
a. Give client mouth care every 2 hr
b. Administer an opioid narcotics to the client
c. Increase temperature to the client's room
d. Insert a nasogastric tube for enteral feeding/
e. Elevate client's head of the bed.
