Depending on the institution and surgeon, a patient will have between two and four chest tubes. The nurse documents chest tube output hourly
What should the nurse do if there is an increase in output of greater than 100 milliliters in 1 hour? Select all that apply. 1. Report to the surgeon.
2. Check the hemoglobin and hematocrit.
3. Administer a blood transfusion.
4. Notify the family.
5. Nothing, as this is normal.
1. Report to the surgeon.
2. Check the hemoglobin and hematocrit.
Rationale: Report to the surgeon. It is abnormal to have greater than 100 milliliters of drainage in 1 hour. It may indicate bleeding and needs to be assessed by the surgeon. Check the hemoglobin and hematocrit. It is abnormal to have greater than 100 milliliters of drainage in 1 hour. It may indicate bleeding; therefore, checking the hemoglobin and hematocrit is indicated. Administer a blood transfusion. The patient needs to be assessed along with the laboratory data before it is determined if a blood transfusion is necessary. Notify the family. There is no need to notify family until the patient has been assessed. It may not be of significance.
Nothing, as this is normal. It is abnormal to have greater than 100 milliliters of drainage in one hour.
You might also like to view...
The nurse is preparing to interview the hospitalized client. Which statements by the client's nurse indicate that the interview should be postponed?
Select all that apply. 1. "I can't seem to get her pain under control this morning." 2. "I just gave her morphine sulfate through her IV for pain about 20 minutes ago." 3. "She was anxious earlier and received some lorazepam." 4. "She's been oriented to 'self' only since admission." 5. "I gave her some ibuprofen about 1 hour ago."
Nurses who have been caring for patients who are terminally ill frequently begin to feel helpless and frustrated. What is best for the nurse to implement when caring for the terminally ill patient?
a. Find another job. b. Express feelings to a friend or coworker. c. Ignore these feelings because they will soon be gone. d. Ask to care for different patients.
A client complains of excessive daytime sleepiness with sudden daytime sleep attacks, cataplexy, and sleep paralysis. You suspect:
1. obstructive sleep apnea. 2. insomnia. 3. primary hypersomnia. 4. narcolepsy.
When planning nursing care, the nurse understands that the main value of having knowledge of a variety of nursing theories is to be able to do which of the following?
1. Promote consideration and use of nursing research. 2. Build the skill and effectiveness of the nurse's practice. 3. Enhance collaboration and understanding between the nurse and the mental health care team. 4. Implement individualized nursing interventions depending on what is best for the client's situation.