Question

Question 4: Multiple Choice- 10 points

The RN and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the RN?

a. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup.

b. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table.

c. The client receiving a biologic response modifier, has a temp of 99.2 F, P 68, R 24 and a B/P of 198/102.

d. The client receiving prednisone is complaining of an upset stomach after eating breakfast.

Response(s)

Rationale

Answer 1

The presence of blood in sputum is common sign for lung cancer and other serious lung infections, It is helpful for a person with chronic emphysema to sit in a tripod position to ease breathing, Prednisolon can cause stomach upsets as it irritate the mucosal lining of the stomach. Although, all these patients need care, the immediate attention to be given to The client receiving a biologic response modifier, has a temp of 99.2 F, P 68, R 24 and a B/P of 198/102, whos blood pressure is very high. It is because the clients who receive biologic response modifiers has a chance of increase in blood pressure to a dangerous levels​​​​​​​ due to the stimulation of the bone marrow by the medication effect.

Thus the options A, B, and D can be excluded and the answer is, C.The client receiving a biologic response modifier, has a temp of 99.2 F, P 68, R 24 and a B/P of 198/102.