The nurse is reviewing the client's medical record.

Exhibits

The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

A. Current level of consciousness. Changes in mental status, such as confusion or decreased alertness, can indicate hypoxia, infection, or worsening respiratory distress. Given the client’s history and symptoms, altered consciousness requires immediate follow-up to assess for possible hypoxemia or sepsis.
B. Heart rate. While the heart rate of 104/min is slightly elevated, it is not critically abnormal. Tachycardia can occur due to fever, anxiety, or respiratory distress, but it is not the most urgent concern compared to other findings.
C. Respiratory rate. The client’s respiratory rate of 30/min is significantly elevated, indicating possible respiratory distress. Increased work of breathing suggests inadequate oxygenation or potential pneumonia, requiring immediate evaluation and intervention.
D. Chronic health condition. The client has Parkinson’s disease and a history of smoking, both of which are important considerations in their overall care but do not require immediate intervention in the current scenario.
E. Tremors. Tremors are a common symptom of Parkinson’s disease and do not indicate an acute emergency. They do not require urgent follow-up in this case.
F. Oxygen saturation level. An oxygen saturation of 89% on room air is concerning, as it indicates hypoxemia. Immediate intervention, such as supplemental oxygen and further respiratory assessment, is necessary to prevent further deterioration.

A. Apply water-soluble lubricant to the site. Lubricants are not necessary for gastrostomy tube site care. Instead, the nurse should keep the area clean and dry to prevent irritation and infection. Applying lubricant could increase moisture, potentially leading to skin breakdown or fungal infections.
B. Attach an extension tube to the site's opening prior to use. Extension tubes are only needed for certain types of gastrostomy devices, such as low-profile buttons, and should be attached only when feeding or administering medications. Continuous attachment is unnecessary and may increase the risk of dislodgment or contamination.
C. Tape the tube to the child's cheek. Taping a gastrostomy tube to the cheek is inappropriate, as it does not provide adequate stabilization and may cause discomfort. This technique is more commonly used for securing nasogastric tubes rather than gastrostomy tubes.
D. Secure the tubing to the child's abdomen. Properly securing the gastrostomy tube to the abdomen helps prevent accidental dislodgment, irritation, and skin breakdown. The tube should be secured with tape or a securement device while allowing slight movement to reduce tension on the insertion site.