A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first?
A. Contact the health care provider
B. Check for kinks in the drainage system
C. Check the client's blood pressure and heart rate
D. Connect a new drainage system to the client's chest tube
Ans: B. Check for kinks in the drainage system
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A woman who is 28 weeks pregnant is admitted to the high-risk OB unit with preterm premature rupture of the membranes. Four hours after admission, the nurse notes the following:
temperature: 38.5 °C (101.5 °F), maternal pulse: 122 beats/minute, and white blood cell count: 23,000 mm3. Which action by the nurse takes priority? A. Document the findings and notify the health-care provider. B. Facilitate fern testing or Nitrazine testing on vaginal fluid. C. Prepare to administer a prn dose of acetaminophen (Tylenol). D. Reassure the woman that these are expected findings.
Which is the most developmentally appropriate intervention when working with the hospitalized adolescent?
a. Encourage peers to call and visit when the adolescent's condition allows. b. Encourage the adolescent's friends to continue with their daily activities; the adolescent has concrete thinking and will understand. c. Discourage questions and concerns about the effects of the illness on the adolescent's appearance. d. Ask the parents how the adolescent usually copes in new situations.
The nurse is preparing to perform a rectovaginal examination on a client. Which statement by the nurse would be most appropriate?
A) "I have to do this exam to make sure everything is okay, so just bear with me." B) "You might feel uncomfortable, almost like you have to move your bowels." C) "Just relax, it will only take a minute and then I'll be all finished." D) "I want you to hold your breath as I insert my fingers into the openings."
The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action?
a. Reduced glomerular filtration b. Reduced esophageal stricture c. Increased gastric motility d. Increased liver mass