The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer.
The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

Choice A rationale:

Total protein is a measure of the overall protein content in the blood. It includes albumin and globulin.

While it can be helpful in assessing nutritional status and liver function, it is not directly relevant to the client's current symptoms of pallor and fatigue.

Decreased total protein can indicate malnutrition or liver disease, but these conditions would not typically cause the specific symptoms of pallor and fatigue.

Therefore, total protein is not the most important laboratory value to review in this case.

Choice B rationale:

Hemoglobin is the protein in red blood cells that carries oxygen throughout the body.

Paleness (pallor) is a common sign of anemia, which is a condition characterized by a low hemoglobin level. Fatigue is also a common symptom of anemia, as the body's tissues are not receiving enough oxygen.

Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), can cause gastrointestinal bleeding, which can lead to anemia. Therefore, it is essential for the nurse to review the client's hemoglobin level to assess for potential anemia.

Choice C rationale:

Glucose is a type of sugar that the body uses for energy.

Abnormal glucose levels can cause various symptoms, including fatigue. However, glucose levels would not typically cause pallor.

Additionally, there is no indication in the question stem that the client has any risk factors for diabetes or other disorders that affect glucose metabolism.

Therefore, glucose is not the most likely cause of the client's symptoms.

Choice D rationale:

Sodium is an electrolyte that helps regulate fluid balance in the body.

Abnormal sodium levels can cause various symptoms, including fatigue and weakness. However, sodium levels would not typically cause pallor.

Additionally, there is no indication in the question stem that the client has any risk factors for electrolyte imbalances. Therefore, sodium is not the most likely cause of the client's symptoms.

B. Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.

Rationale:

Hypoxemia: Patients who have undergone cholecystectomy are at risk for developing hypoxemia due to various factors, including:

Atelectasis: Collapsed lung tissue can impair gas exchange, leading to low oxygen levels in the blood.

Pneumonia: A potential post-operative complication that can cause inflammation and fluid buildup in the lungs, hindering oxygen uptake.

Pain: Post-surgical pain can inhibit deep breathing and coughing, which are essential for maintaining adequate lung function.

Oxygen Therapy: Supplementing oxygen helps to increase oxygen saturation and improve overall tissue oxygenation, reducing the strain on the heart and other organs.

Oxygen Saturation Goal: Maintaining oxygen saturation at or above 95% ensures that the patient's tissues are receiving sufficient oxygen to meet their metabolic needs.

C. Stat 2 views chest x-ray.

Rationale:

Chest X-ray: A valuable diagnostic tool that can visualize the lungs and surrounding structures, aiding in the assessment of: Atelectasis: Appears as areas of increased density on the x-ray, indicating collapsed lung tissue.

Pneumonia: May present as consolidation (solid white areas) or infiltrates (patchy areas of increased density) on the x-ray. Pleural effusion: Fluid accumulation in the pleural space, which can impair lung expansion and gas exchange.

Pneumothorax: Presence of air in the pleural space, which can cause lung collapse and respiratory distress.

Early Detection: Prompt identification of respiratory complications through chest x-ray allows for timely interventions and prevents further deterioration of the patient's condition.

E. Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Rationale:

CBC: Assesses for signs of infection or inflammation, including:

Elevated white blood cell count (leukocytosis) Increased neutrophils (neutrophilia)

Anemia (low red blood cell count)

BMP: Evaluates electrolyte and kidney function, which can be affected by infections and post-operative complications.

Blood Cultures: Determines the presence of bacteria in the bloodstream, allowing for identification of the causative organism and guiding appropriate antibiotic therapy.

F. Start the patient on antibiotic therapy.

Rationale:

Infection Risk: The patient's history of cholangitis and recent surgery increase the risk of infection. Prophylactic Antibiotics: Often administered after cholecystectomy to prevent post-operative infections.

Early Intervention: Prompt initiation of antibiotic therapy is crucial in managing infections and preventing serious complications such as sepsis.