The nurse notes intermittent bubbling in the water-seal chamber of a chest tube in place for a client with pneumothorax. The nurse's most appropriate action is to
a. change the drainage unit.
b. clamp the chest tube.
c. encourage respiratory exercises.
d. place petrolatum gauze around the chest tube.
C
Bubbling in the water-seal compartment is caused by air passing out of the pleural space into the fluid in the bottle. Intermittent bubbling is normal when the lung is still expanding. Respiratory exercises will hasten the lung's reexpansion.
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An elderly patient in the CCU is getting out of bed for the first time after being on bed rest for several days. What is the highest-priority nursing intervention?
A) Provide adequate physical help so that the patient does minimal weight bearing. B) Ensure that the patient's call light is always within reach. C) Apply a vest restraint while the patient is up to prevent falling. D) Have the patient sit on the side of the bed for a few minutes before standing.
A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An ap-propriate nursing intervention when caring for an infant with hyperbilirubinemia and re-ceiving phototherapy by this method would be to:
a. Apply an oil-based lotion to the newborn's skin to prevent drying and cracking. b. Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. c. Place eye shields over the newborn's closed eyes. d. Change the newborn's position every 4 hours.
Which safety precaution should you teach a patient who is prescribed eye drops or eye ointment?
a. "Wash your hands before and after applying the drug." b. "Do not share your eye medications with anyone else." c. "Avoid drinking alcoholic beverages while taking this drug." d. "Do not drive or use heavy equipment while your vision is blurred."
You see a nursing assistant hitting a resident. What should you do?
a. Talk to the resident. b. Call the police. c. Tell the administrator. d. Mind your own business.