A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A. "Enjoy the time you have and do the things you want to do":

While this response may seem supportive, it does not address the client's expressed desire for aggressive treatment. It is important for the nurse to acknowledge the client's wishes and provide appropriate support and information to help them make decisions about their care.

B. "Hospice care is the best thing for you at this time":

While hospice care may be appropriate for some clients with terminal illnesses, it is not appropriate to assume that it is the best option for every client. The nurse should not impose their own beliefs or preferences onto the client and should instead support the client in exploring their options and making decisions based on their individual needs and preferences.

C. "You need to understand that you have very little time left":

This response may be seen as dismissive or insensitive to the client's wishes for aggressive treatment. It does not acknowledge the client's autonomy or right to make decisions about their own care. The nurse should approach the situation with empathy and respect for the client's wishes, while also providing support and information to help them make informed decisions.

D. "I will contact your provider to discuss your options."

The client has expressed a desire for aggressive treatment, and it is important for the nurse to respect the client's autonomy and preferences. By stating that they will contact the provider to discuss the client's options, the nurse ensures that the client's wishes are communicated effectively and that they receive appropriate information and support to make informed decisions about their care.

A. Check the pH level of the client's gastric contents:

Checking the pH level of gastric contents is not typically necessary before administering intermittent tube feeding. pH testing of gastric contents is more commonly performed for clients with nasogastric tubes to confirm tube placement within the stomach. It is not routinely done before administering tube feeding through a percutaneous gastrostomy tube.

B. Check the patency of the client's tube every 8 hr:

While it is essential to check the patency of the tube regularly, every 8 hours may not be frequent enough, especially for clients receiving intermittent tube feedings. Tube patency should be checked before and after each feeding or medication administration to ensure proper function and prevent complications.

C. Place the client in a supine position:

Placing the client in a supine position is not specifically indicated for administering intermittent tube feedings. The client's position during tube feeding administration depends on individual factors such as comfort, mobility, and risk of aspiration. The nurse should position the client in a semi-upright or upright position (typically at a 30-45 degree angle) to reduce the risk of aspiration.

D. Flush the client's tube with 5 mL of water.

Flushing the client's tube with water helps ensure its patency and removes any residual feeding solution or gastric contents, reducing the risk of clogging and infection. Flushing with 5 mL of water is a common practice to maintain tube patency and should be done before and after each feeding and medication administration.