The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

a. Document the amount of drainage every eight hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level.


ANS: A
UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

Nursing

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A competent older adult patient has a living will stating that resuscitation and heroic life support measures are to be avoided. The family members are not supportive of this directive. Which action by the nurse is the most appropriate?

1. Place the document on the chart. 2. Contact the Social Services department. 3. Notify the hospital attorney. 4. Explain to the patient that the conflict could invalidate the document.

Nursing

The family of a mechanically ventilated client receiving a chest tube asks why the tube is necessary. The nurse responds:

1. "The chest tube helps to decompress the lung and prevents further complications.". 2. "The chest tube helps the client breathe more easily when on a ventilator.". 3. "The chest tube is an elective procedure that many health care providers like to perform.". 4. "The chest tube requires the client to go to surgery for placement.".

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The nurse is assessing a patient at risk for valvular disease and finds pitting edema. This finding is a sign for which type of valvular disease?

a. Mitral valve stenosis and insufficiency b. Aortic valve stenosis and insufficiency c. Tricuspid valve prolapse d. Mitral valve prolapse

Nursing

Which procedure would you expect the attending physician to order for C.B. and why?

What will be an ideal response?

Nursing