A nurse determines that there may be a leak in the chest tube system. Clamps are applied near the client's chest, and the nurse finds that the bubbling stops. The nurse should:
A. Change the tubing
B. Change the drainage container
C. Move the clamps farther down the chest tube
D. Reinforce the dressing and notify the physician
D
D. Assess for the location of the air leak by clamping chest tube close to the chest wall with two shodded hemostats. If the bubbling stops, the leak is inside the thorax or insertion site. Unclamp the tube, reinforce the dressing, and notify the physician immediately.
A. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing away from the client. If bubbling stops, replace the tubing or secure the connections.
B. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing away from the client. If bubbling continues, replace the drainage system.
C. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing away from the client. If bubbling stops, replace the tubing or secure the connections. If bubbling continues, replace the drainage system.
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Mr. Mitchell is 88 years old. He refuses to come to meals, and when he does, he cannot sit down long enough to eat. His daughter has commented that his clothes are hanging from his body. To improve his nutritional status, you
a. Use body restraints for meals b. Increase his food choices c. Call the physician for medication to alter his behavior d. Provide him with sandwiches, small pieces of fruit and cheese, and spill-proof drink containers
How do practice pattern profiling and nursing-sensitive patient outcomes research relate to one another?
a. The identification of nursing-sensitive patient outcomes is a type of practice pattern profiling. The purpose of both is to identify the outlier, so as to improve patient outcomes. b. Practice pattern profiling scrutinizes an individual in comparison with a group; nursing-sensitive patient outcomes research addresses nurses as a group, rather than as individuals. c. Both can identify variables that affect patient outcome. d. Both pose risk to the person who delivers care. e. Neither can be undertaken without signed consent from the participants. f. Both are types of outcomes research.
Sally comes in for her first prenatal examination. This is her first child. She asks you (the nurse), "How does my baby get air inside my uterus?" The correct response is
a. "The baby's lungs work in utero to exchange oxygen and carbon dioxide." b. "The baby absorbs oxygen from your blood system." c. "The placenta provides oxygen to the baby and excretes carbon dioxide into your bloodstream." d. "The placenta delivers oxygen-rich blood through the umbilical artery to the baby's abdomen."
A 35-year-old client had a normal, spontaneous vaginal delivery. The mother's social
history includes use of oral contraceptives and smoking. The physical appearance and chromosomal studies for the baby confirm Down syndrome. Which feature would be seen in the baby? A) Large, round head B) Big, pointed nose C) Small, high-set ears D) Small, low-set ears