A patient with a history of squamous cell lung cancer is admitted to the hospital with arm and periorbital edema. After a few hours, the patient exhibits dyspnea, cyanosis, tachypnea, and an altered level of consciousness
Which action should the nurse take first?
1. Administer oxygen.
2. Call the physician.
3. Monitor vital signs.
4. Initiate seizure precautions.
Correct Answer: 1
The superior vena cava can be compressed by mediastinal tumors or adjacent thoracic tumors. The most common cause is small-cell or squamous-cell lung cancers. Signs and symptoms can develop slowly, and include facial, periorbital, and arm edema as early signs. As the problem progresses, respiratory distress, dyspnea, cyanosis, tachypnea, and altered consciousness and neurologic deficits can occur. Emergency measures include the following: provide respiratory support with oxygen, and prepare for a tracheostomy; monitor vital signs; administer corticosteroids to reduce edema; if the disorder is due to a clot, administer antifibrinolytic or anticoagulant drugs; provide a safe environment, including seizure precautions. The nurse should provide oxygen before contacting the physician or monitoring vital signs. Seizure precautions would not be initiated first.
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