A nurse is educating a terminally ill patient about declining resuscitation in a living will.
The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.

Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.

Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.

Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.

Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.

Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.

Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.

Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.

The client is at risk for Bleeding as evidenced by the Decrease in Platelet count from 350,000/mm² to 100,000/mm².

Rationale for Bleeding: Platelets are a crucial component of the blood that helps in clotting and preventing excessive bleeding. A decrease in platelet count from 350,000/mm² to 100,000/mm² is significant and puts the client at risk for bleeding. This is because when platelet levels fall below the normal range (150,000 to 400,000/mm²), the body’s ability to form clots and stop bleeding is compromised.

Rationale for Anemia: The client’s Hemoglobin level has decreased from 15 g/dL to 12 g/dL, which is at the lower end of the normal range (12 to 16 g/dL). However, it is still within the normal range, so the client is not currently at risk for anemia.

Rationale for Infections: The client’s White Blood Cell (WBC) count has decreased from 8,000/mm² to 6,000/mm², but it is still within the normal range (5,000 to 10,000/mm²). Therefore, the client is not currently at risk for infections.

Rationale for Cardiac arrhythmias: The client’s Potassium level has slightly decreased from 3.7 mEq/L to 3.6 mEq/L, but it is still within the normal range (3.5 to 5 mEq/L). Therefore, the client is not currently at risk for cardiac arrhythmias.