The nurse is providing care for a patient with a pneumothorax. She anticipated removal of the chest tube because of the absence of an air leak for the past _____ hours
a. 6 to 8
b. 12 to 16
c. 18 to 24
d. 48 to 72
C
One of the signs that indicate that the chest tube may be removed is lack of an air leak for 24 to 48 hours. Lack of an air leak for less than 24 hours is usually not long enough, and there is no need to wait 4 days. Other findings that indicate that the chest tube may be removed include a chest x-ray showing lung reexpansion, minimal tube drainage, and lack of water-seal tidaling.
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During a home visit an older patient who is terminally ill can no longer talk. What assessment data will the nurse use to determine if the patient is in pain?
1. Cool, dry skin 2. Moaning while being turned 3. Cyanotic feet and lower legs 4. Cheyne-Stokes respiratory pattern
Collaboration in health care settings involves
a. professionals respected for their unique knowledge and abilities. b. professionals educated in a collaborative model of education. c. recognition of individual professional accomplishments. d. a multitiered system hierarchy.
The nurse is caring for a patient with an external fixator device. What care should the nurse provide to this patient?
1. cleansing pin sites per orders to reduce the chance of infection 2. adjusting the tension on the pins whenever the patient experiences pain 3. explaining that bathing in a tub can be resumed after 3 days 4. encouraging the patient to keep the limb with the external fixator very still.
A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
a. Preparing to administer a barium enema b. Withholding narcotic pain medication c. Administering laxatives to the patient d. Raising the head of the bed