Select the nursing action that takes highest priority in the care of a client with a chest tube connected to a closed underwater-seal drainage system
a. Strip or milk the chest and drainage tube every 2 hours.
b. Make sure there is continuous bubbling in the underwater-seal chamber.
c. Record the amount of drainage in the drainage collection chambers every 8 hours.
d. Hang the drainage collection system at chest level to promote optimal function.
C
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A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would:
a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object.
An emergency department patient is diagnosed with a hip dislocation. The patient's family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency
What is the rationale for the nurse's statement? A) The longer the joint is displaced, the more difficult it is to get it back in place. B) The patient's pain will increase until the joint is realigned. C) Dislocation can become permanent if the process of bone remodeling begins. D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.
The nurse is glad to see that the 3-month-old is going to be casted with a synthetic cast because synthetic casts: (Select all that apply.)
a. Dry quicker b. Do not cause circulatory problems c. Are lighter d. Allow for greater mobility e. Can be modified and reused
A client experiencing pain after surgery says "Something must be wrong," since the pain is so severe. The best response for the nurse to make to the client would be:
1. "The amount of tissue disrupted from the surgery is not related to the degree of pain you feel." 2. "That could be so." 3. "Taking pain medication for many years has made the medication ineffective now." 4. "Are you sure the pain is as bad as you are saying it is?"