A client has a mediastinal chest tube. Which symptoms require the nurse's immediate interven-tion? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Oxygen saturation greater than 95%
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Pain at insertion site
g. Disconnection at Y site
B, D, E, G
Immediate intervention is warranted if the client has tracheal deviation because this could indi-cate a tension pneumothorax; sudden shortness of breath because this could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax; or drainage greater than 70 mL/hr because this could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.
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The nurse is performing a focused interview with the client and asks the client if there has been any drainage from the ears. The client responds, "Yes." Which statement by the health care provider indicates that the client may have developed acute otitis
1. "The ear canal itself is really red, raw, and sore." 2. "I noticed that the drainage looked clear, like water." 3. "The drainage looks like what is draining from my nose, kind of clear and mucous-like." 4. "It is kind of yellowish-reddish color."
The desired outcome from humor therapy is:
A. The patient will feel accepted. B. The patient will have increased feelings of depression. C. The patient will demonstrate a more positive outlook. D. The patient will be discharged sooner.
A client has returned to the nursing unit after a prostatectomy. Which activities does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Demonstrating how to use the incentive spirometer b. Measuring and recording output from the in-dwelling catheter c. Encouraging the client to get out of bed and into the chair d. Irrigating the catheter with normal saline for blood clots e. Re-taping the catheter tape if the client reports pain
Even though a client has completed a course of chemotherapy and has been found to be cancer free at this time, she continues to experience fatigue. Which of the following should the nurse instruct this client?
1. Fatigue is the first warning sign of cancer and should be reported to the physician. 2. Fatigue indicates a poor diet. 3. Fatigue is caused by poor fluid intake. 4. Fatigue can persist after treatment ends, but it will eventually improve.