The client receives a chest tube for a spontaneous pneumothorax. Which does the nurse implement?
1. Applies a sterile, occlusive dressing
2. Strips chest tube to promote drainage
3. Keeps tubing hanging over the bedside
4. Assesses client an hour after insertion
1
1. The nurse applies a sterile occlusive dressing around the base of the chest tube to prevent air leaks. The nurse uses sterile petrolatum gauze and wraps it around the chest tube, pressing it down and around the tube; then the nurse uses a heavy dry gauze dressing over the petrolatum gauze and tapes over all gauze.
2. Stripping tubes is contraindicated to prevent tissue damage.
3. Chest tube tubing remains on the bed to prevent air leaks in the system.
4. The nurse assesses the client every 15 minutes after chest tube insertion.
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The nurse is caring for a client with lymphedema of the left arm in the clinic
The nurse measures a circumference of the affected extremity 4 cm larger in circumference than the opposite limb, and the client complains of feeling a heaviness and pain. There is limited movement of the left arm. What would the nurse grade and document this lymphedema as? A) Grade I (Mild) B) Grade II (Moderate) C) Grade III (Severe) D) Grade IV (Grossly edematous)
Which clinical manifestation during the actual bone marrow transplantation alerts the nurse to the possibility of an adverse reaction?
A. Fever B. Red urine C. Hypertension D. Shortness of breath
Which activity would support the client's use of mind–body interventions and require privacy?
1. Reading 2. Praying 3. Practicing aromatherapy 4. Meditation
The 75-year-old patient is preparing for discharge and tells the case manager, "I don't know what I am going to do when I get home. I cannot afford the medications the doctor has ordered for me
" What is the case manager's most appropriate response? a. "We can have a social worker see you when you get home." b. "Medications are expensive, but you will need to take them." c. "I can speak with your doctor about discontinuing some of the medications." d. "The home health nurse will address this when she sees you."