An infant has had surgery to correct a congenital heart defect. The physician placed a chest tube in the infant. The nurse should carry out which of the following interventions to maintain the integrity of the tubes:
a. Maintain the bottles above the level of the chest
b. Keep rubber-shod Kelly clamps available at all times
c. Have a sterile gauze dressing available to place over the site if the tube is removed
d. Do not allow the infant to be transported until the tubes are removed
B
The drainage bottles must be kept below the level of the chest to prevent the backflow of drainage. The rubberized Kelly clamps must be available at all times in case the tube breaks. A sterile petroleum gauze is also always available to place over the site when the tubes are removed. The infant can be transported, but with care to maintain integrity of the suction.
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A. Administer naloxone (Narcan) per protocol. B. Discontinue the patient's intravenous infusion. C. Have ephedrine ready for administration. D. Place a wedge under the patient's left hip.
The nurse is conducting a class for senior citizens about the use of over-the-counter (OTC) drugs. Which statements are true regarding the use of OTC drugs?
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The nurse is assessing a patient's skin and notes jaundice, a yellow discoloration of skin. Which conclusion by the nurse is most appropriate based on this assessment finding?
1) Impaired cardiovascular circulation 2) Diminished oxygen concentration 3) Liver impairment 4) Renal impairment
The nurse is performing a head-to-toe assessment. Organize the areas that need to be assessed into the order in which the nurse would examine them
1. Ears and eyes Response 2. General appearance Response 3. Respiratory and cardiac systems Response 4. Neurologic status Response 5. Abdomen and GI system