A pаtient is receiving 3% NаCl sоlutiоn fоr correction of hyponаtremia. The nurse recognizes that this treatment can lead to potential complications. Which assessment is most critical for the nurse to prioritize in managing the patient's care during this infusion?
Scenаriо: A 48-yeаr-оld wоmаn had a lumpectomy after being diagnosed with carcinoma in the left breast. She had her first chemotherapy treatment with cyclophosphamide 2 months ago. Today she is in the outpatient cancer treatment center for her sixth round of chemotherapy; radiation therapy is planned after the tenth chemotherapy treatment is completed. The nurse documents these findings as part of today’s admission assessment: Reports “feeling tired often.” “I have had diarrhea five or six times a day.” “I don’t have much of an appetite.” “I have noticed some blood in my urine, starting yesterday.” “My food doesn’t have any taste to it at all.” The patient has alopecia. Oral mucosa is inflamed with some ulcerations noted in the cheek areas. Vital signs: Temperature 100.5°F (38.1°C), Pulse 88, Respirations 12, blood pressure 118/72 Scenario: After further assessment, the patient indicated that she was menstruating. As a precaution, the chemotherapy treatment was postponed and the patient was scheduled for a follow-up in 1 week. At the follow-up appointment, her urinalysis was negative for red blood cells and the oncologist added immunotherapy to the treatment plan. The patient received the first dose of interferon and continued with the cyclophosphamide therapy. Scenario: At 10 weeks, the oncologist changed the treatment plan to include radiation therapy and continued interferon therapy. The patient will now receive external beam radiation therapy 5 days a week for 6 weeks. After the first two radiation treatments, the patient noticed that the skin around the treatment area was reddened and swollen. The nurse evaluates the effectiveness of actions for the patient's plan of care. Based on the last scenario, which of the following findings indicate effectiveness? Select all that apply.