The nurse is caring for a client who has a chest tube to suction with a closed drainage
system. Which of the following findings should the nurse investigate further?
A. Subcutaneous emphysema in upper chest.
B. Tidaling (fluctuation) of fluid in the water-seal chamber.
C. Continuous air bubbling in the suction-control chamber.
D. Pain in the chest at insertion site rated "8" (0-10).
A. Emphysema reflects air is leaking beneath skin.
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ABX treatment post osteomyelitis
Parenteral ABX for 4-8 weeks
Oral ABX for 4-8 weeks
A female client with hyperesthesia who is on the oncology unit and receiving a TENS unit
for chronic pain. Which nursing action should the nurse perform and not delegate to a
practical nurse (PN)?
Measure the client's level of discomfort by asking for a pain rating scale.
Ask the client to describe any former experiences related to chronic pain.
Observe the client for pain and discomfort evidenced by facial expressions.
Evaluate the client's ability to self-regulate the voltage to manage pain.
D.
The oncology nurse is knowledgeable about and experienced with the use of a TENS
unit for the relief of chronic pain, so the nurse should assess the client's ability to
manage the pain appropriately by adjusting the voltage.
The nurse is providing postoperative instructions for a female client following a
mastectomy. Which information should the nurse include in the teaching plan? (Select
, all that apply.)
Select all that apply
Empty surgical drains weekly with the use of procedure gloves.
Report redness of the incision site or the involved arm.
Wear clothes with tight-fitting sleeves on the operative side of the arm.
Avoid lifting over 4.5 kg (10 lb) or reaching above her head.
B, D
While planning the care for a patient who has had an acute stroke with resulting
right-sided hemiplegia, the nurse should position the client in which of the following to
help maintain optimal function?
Mid-Fowler's with knees supported.
Supine with trochanter rolls to hips.
Sim's position was changed to right lateral position q2 hours.
Left lateral, supine, brief periods on right side, and prone.
D.
A turning and positioning schedule that minimizes lying on the affected side to prevent
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