A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assessfirst?
A. The client's vital signs
B. The amount of drainage
C. The client's lung sounds
D. The chest tube connections
Answer: D. The chest tube connections
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A patient with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective?
A) The patient's PT is within reference ranges. B) Arterial blood sampling tests positive for the presence of factor XIII. C) The patient's platelet level is below 100,000/mm3. D) The patient's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.
The home health nurse is alarmed that the hypertensive patient's blood pressure has risen to 200/160, but he denies any discomfort. The nurse interprets these assessments as being indicative of:
a. malignant hypertension. b. hypertensive crisis. c. essential hypertension. d. secondary hypertension.
For a client experiencing urinary incontinence, in the initial plan of care the nurse would include
a. encouraging the client to void frequently. b. limiting fluid intake. c. teaching Kegel exercises. d. using adult diapers to prevent accidents.
Techniques of testing for possible allergy include: (Select all that apply.)
a. the scratch test. b. drinking diluted solution of antigen. c. intradermal injection. d. dropping solution in the eye. e. adhesive patches.