A nurse is caring for a client on the oncology unit who is experiencing multiple symptoms and requiring close monitoring. The client appears fatigued and has recently experienced significant weight loss. Nurse's Notes: 1030- Client reports increased fatigue and shortness of breath when ambulating. Weight has decreased by 10 lbs over the past month. Lung sounds are diminished bilaterally, and slight cyanosis is noted around the lips. Vital Signs at 1000: Temperature 36.7 C (98.1 F), Heart Rate 110/min, Respiratory Rate 22/min, Blood Pressure 110/70 mmHg, Oxygen Saturation 94 Vital Signs at 1400: Temperature 37.2 C (99 F), Heart Rate 95/min, Respiratory Rate 24/min, Blood Pressure 100/65 mmHg, Oxygen Saturation 92 Laboratory Results at 1400: Hgb 9.3 gm/dL, Platelets 70,000 mcL, WBC 8,000 mcL, BUN 24 mg/dL. 1430- Client expresses concern about swelling in the abdomen and has not had a bowel movement in three days. Abdomen is distended and tender to palpation, with hypoactive bowel sounds. Based on the given scenario, which nursing action is the priority for the client's current status?

Choice A rationale While the client reports abdominal distension, tenderness, and a lack of bowel movements, administering a stimulant laxative is not the most urgent priority compared to respiratory compromise. Constipation and hypoactive bowel sounds indicate a potential paralytic ileus or obstruction, which requires further diagnostic evaluation before stimulating peristalsis. While important for comfort and gastrointestinal function, this intervention does not address the immediate life-threatening issues of hypoxemia or potential respiratory failure noted in the assessment. Choice B rationale Increasing the frequency of vital sign monitoring to every 15 minutes provides more data but does not directly treat the client's current physiological distress. The client's blood pressure is dropping and their oxygen saturation has decreased from 94 to 92. While frequent monitoring is necessary in an unstable patient, the priority nursing action must be an intervention that stabilizes the patient's condition. Observation alone cannot correct the worsening oxygenation or the underlying cause of the client's respiratory and circulatory decline. Choice C rationale The client is demonstrating signs of respiratory distress, including a respiratory rate of 24, decreased oxygen saturation of 92, cyanosis, and diminished lung sounds. The hemoglobin level is also low at 9.3 gm/dL, which reduces the oxygen-carrying capacity of the blood. Normal hemoglobin for an adult is generally 12 to 18 gm/dL. Applying supplemental oxygen is the priority to ensure adequate tissue perfusion and prevent further cellular hypoxia, especially given the client's oncology status and recent clinical deterioration. Choice D rationale Significant weight loss and fatigue suggest that the client is in a catabolic state or experiencing cancer-related cachexia, making nutritional support essential for long-term recovery. However, nutritional interventions are considered a secondary priority when a client is experiencing acute physiological instability such as worsening oxygenation and potential shock. The immediate focus must remain on the ABCs of nursing care. Once the respiratory and hemodynamic status is stabilized, the nurse can then implement strategies to improve the client's caloric and protein intake. .