The nurse caring for a client with a chest tube to water seal is bathing and changing the linen when the sealed drainage system becomes damaged and the client suddenly becomes short of breath. The nurse's priority action is to:
1. Clamp the chest tube closer to the client.
2. Have the client cough forcefully.
3. Connect a new sealed drainage system.
4. Notify the charge nurse and physician.
1
Rationale: This is an emergency situation, because air now can enter the client's pleural cavity, so the immediate intervention by the nurse is to clamp the chest tube until a new sealed drainage system can be obtained and connected. Coughing forcefully will do nothing for the client. After clamping the chest tube, the nurse can call for help to obtain a new system while staying with the client, elevating the head of the bed, applying oxygen, and monitoring the client's condition. An incident report should be completed when the client is stabilized.
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a. "This drug will prevent seizures, which can occur because of trigeminal disease." b. "I expect to have surgery soon, so I can stop taking this drug now." c. "This medication is very successful in re-lieving pain. I am glad to be taking it." d. "I will avoid drinking alcohol because it can add to the side effects of this medi-cine."
The client's values
a. must coincide with those of the nurse. b. are only considered during assessment. c. influence the nurse's interventions. d. are not influenced by culture.
A client is reporting intermittent pain in the left upper abdomen. In order to best assess the characteristics of the pain, the nurse asks the client: Select all that apply
1. "Can you do anything that makes the pain go away?" 2. "Does anything make the pain worse?" 3. "When did you first notice the pain?" 4. "Can you describe the pain for me?" 5. "What do you think is causing the pain?"