The client's chest tubes are being removed today by the provider. Which does the nurse implement for chest tube removal? (Select all that apply.)
1. Positions the client
2. Assesses the client
3. Removes the sutures
4. Holds occlusive dressing
5. Applies manual pressure
6. Premedicates with analgesic
1, 2, 6
1. The nurse assists during chest tube removal by medicating the client beforehand with analgesia, positioning the client, and assessing the client before and after the procedure. The nurse positions the client comfortably and to provide full access to the chest tube insertion site.
2. The nurse assesses the client before the procedure to ensure no contraindications to removal exist and to establish baseline data including breath sounds, regional crepitus, EKG, and vital signs. Following the procedure, the nurse assesses the client fre-quently for early detection of complications.
6. Chest tube removal is very painful, usually; so, the nurse premedicates the client to blunt the pain's severity.
3, 4, and 5. The provider removes the chest tube and begins the procedure by clipping the sutures holding the chest tube in place, holding the occlusive dressing over the insertion site, and removing the chest tube in one, quick maneuver. Generally, the nurse avoids applying manual pressure because the occlusive sterile prevents air being drawn into the chest tube site and besides, manual pressure is an intervention suitable to stop bleeding.
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The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable?
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A client who underwent surgery is intubated and receiving mechanical ventilation. The client is receiving a neuromuscular blocking agent to stop spontaneous breathing that is not in synchrony with the ventilator
The appropriate approach by the nurse to the client's postoperative pain control would be a. a sedative should be given with an anxiolytic and the neuromuscular blocker to control pain. b. an analgesic is needed specifically for pain control and must be given as needed along with the neuromuscular blocker and a sedative or anxiolytic. c. sedatives should be given with the neuromuscular blocking agent, and together these will control pain. d. the neuromuscular blocking agent will prevent pain impulse transmission, so the prn analgesic order is unnecessary.