A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? (Select all that apply.)

Choice A: Reassess the client and the level of pain is the correct intervention because it helps the nurse evaluate the effectiveness of the medication and plan further actions. The nurse should use a valid and reliable pain scale and check for any signs of adverse effects or complications.
Choice B: Tell the client the medication needs more time to work is not a correct intervention because it may dismiss the client’s pain and delay appropriate treatment. The nurse should acknowledge the client’s pain and explain the expected onset and duration of the medication.
Choice C: Ask the UAP to offer a backrub to the client is not a correct intervention because it may not be sufficient or appropriate for the client’s pain. The nurse should assess the client’s pain before delegating any nonpharmacological interventions to the UAP.
Choice D: Encourage the client to focus on taking deep breaths is not a correct intervention because it may not be effective or feasible for the client’s pain. The nurse should assess the client’s pain and offer other complementary therapies that are suitable and acceptable for the client.

Choice A reason: This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.

Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.

Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.