The nurse is assessing a client who is 6 hours postoperative from coronary artery bypass graft surgery. The client's mediastinal tubes are not draining. Which action does the nurse implement at this time?
a. Replace the drainage tubing.
b. Check for kinks in the tubing.
c. Irrigate the tubing with normal saline.
d. Document the finding.
B
Sudden cessation of mediastinal drainage could result in cardiac tamponade from accumulation of blood around the heart. If the tubing is kinked, this can be addressed quickly. If the tubing is not kinked, immediate notification of the provider is required. The other actions do not correctly address the problem.
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Which of the following is not a level of consciousness?
a. Lethargic b. Alert c. Oriented d. Comatose
During the assessment of a client's voice sounds, the nurse hears louder sounds over the client's right lower lobe. This finding would be consistent with:
1. Atelectasis. 2. Lobar pneumonia. 3. Asthma. 4. Pleural effusion.
A patient on didanosine telephones to report the recent onset of abdominal pain, nausea, and vomiting. Select the nurse's best course of action
1. Reassure the patient that viral gastroenteritis is likely and should be self-limiting. 2. Stop the medication until the symptoms are resolved, and restart as prescribed. 3. Advise the patient to come to the clinic immediately to be evaluated for pancreatitis. 4. Provide antiemetics and give instructions for clear liquids until the symptoms resolve.
T.B.'s other laboratory results are posted and you review them
Which results are abnormal, and what do they reflect?