The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?
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A client is brought into the emergency department after aspi…
A client is brought into the emergency department after aspirating on pureed foods at the long-term care facility. The nurse knows that which physiologic change can trigger acute respiratory distress syndrome?
When planning care for a patient on a mechanical ventilator,…
When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?
The nurse on the medical-surgical unit is caring for a 69-ye…
The nurse on the medical-surgical unit is caring for a 69-year-old male client with pain and swelling of the right lower extremity. Nurses’ Notes Day 1. 0930 Admission note: Client admitted from the Emergency Department via stretcher and transferred to bed. Client is alert and oriented. Saline lock IV in the R antecubital vein patent. Right lower extremity noted to have 2+ pedal edema, pain 8/10 in right calf. Warmth noted to right calf. Positive Homan’s sign to R lower extremity noted. Client has positive motion and sensation to right lower extremity. Right pedal pulse weak, palpable. R lower extremity elevated on 2 pillows. VS: BP 145/82, HR 96, RR 16, Temp 36.7C (98F). Client ordered to be on complete bedrest. Client made aware. 1010: Radiology called results of right leg ultrasound: Positive for deep vein thrombosis of the right posterior tibial vein. Provider made aware. New orders pending. 1030: Patient begins to experience SOB, anxiety, O2 Sat 83%, RR 38, HR 108, BP 149/88, patient seems to be apprehensive and anxious Which of the following actions should the nurse anticipate including in the patient’s plan of care? Select all that apply
A patient in acute respiratory failure is receiving ACV with…
A patient in acute respiratory failure is receiving ACV with a positive end-expiratory pressure (PEEP) of 10 cm H20. What sign alerts the nurse to undesirable effects of increased airway and thoracic pressure?
Nurse Oliver observes constant bubbling in the water-seal ch…
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
A female client with chest injury has suffered flail chest….
A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest?
The RN is supervising a nursing student who will suction a p…
The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? Select all that apply.
A client with a tracheostomy is at increased risk for aspira…
A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? Select all that apply
Mr. G requires neuromuscular blockade to facilitate mechanic…
Mr. G requires neuromuscular blockade to facilitate mechanical ventilation. Which is not a true statement when providing nursing care to paralyzed patients?