A nurse is assessing a client who reports having an unusual rash on the palms of their hands and bottom of their feet. The nurse should further assess for which of the following infections?

Rationale:

A. While moisturizing is important for dry skin, “liberally applying lotions” is not recommended in clients receiving radiation therapy. Lotions or creams should be used cautiously and only those approved by the radiation oncology team. Some products can irritate the skin or interfere with radiation treatment if applied improperly.

B. Skin markings (tattoos or ink markings) are used to ensure precise targeting of radiation therapy. They should never be removed during the treatment course because they guide accurate positioning. Even after treatment, removal is not typically a nursing recommendation during therapy.

C. Radiation-treated skin is highly sensitive and more prone to damage from sun exposure. Protective clothing (such as soft, loose-fitting garments and covering the area when outdoors) helps prevent irritation, burns, and further dryness. Sun protection is a key teaching point during radiation therapy.

D. Harsh or antibacterial cleansers can dry and irritate irradiated skin. Gentle cleansing with mild soap and lukewarm water is recommended instead to avoid further skin breakdown or discomfort.

Rationale for Correct Choices

• Pulmonary embolism: The client presents with sudden, severe chest pain rated 10/10, tachycardia (122/min), tachypnea (25/min), hypotension (77/45 mm Hg), and hypoxemia (SpO₂ 85%). These findings are consistent with a massive pulmonary embolism causing impaired pulmonary circulation and right-sided cardiac strain. Anxiety and “feels like something bad is going to happen” are also common subjective findings.

• Elevate head of the bed: This positioning improves lung expansion, decreases work of breathing, and enhances oxygenation in a client with impaired pulmonary perfusion.

• Administer anticoagulant: Anticoagulants (e.g., heparin) are first-line treatment to prevent further clot formation and reduce progression of the embolism.

• Respiratory effort: Monitoring work of breathing helps evaluate worsening hypoxia and effectiveness of oxygenation/ventilation support.

• aPTT (pTT): If heparin is used, aPTT is monitored to ensure therapeutic anticoagulation and prevent bleeding complications

Rationale for Incorrect Choices

• Tension pneumothorax: Would present with absent or markedly diminished breath sounds on one side, tracheal deviation, and unilateral chest findings—none are present (lung sounds are vesicular bilaterally and trachea is midline).

• Gastric reflux disease: Would cause burning epigastric pain, often related to meals, not severe hypoxia, hypotension, or tachycardia.

• Palpitations: Would not explain severe hypotension, hypoxemia, or respiratory distress.

• Teach client to avoid fried and spicy foods: Appropriate for GERD, not acute cardiopulmonary collapse.

• Encourage client to consume less caffeine: May reduce palpitations or anxiety symptoms but does not address life-threatening hypoxia and hypotension.

• Assist with chest tube insertion: Indicated for tension pneumothorax, not pulmonary embolism.

• Chest tube drainage: Not applicable because no chest tube is indicated for pulmonary embolism.

• Heart rate irregularity: Not the primary issue; tachycardia is present but rhythm irregularity is not described.

• Epigastric pain: Not consistent with the presenting cardiopulmonary emergency.