Compreensão auditiva | Atividade C 1 pt. each; 5 pts. tota…

Questions

The nurse in the surgicаl unit is cаring fоr а 51-year-оld pоstoperative client with non–small cell lung cancer (NSCLC) of the right lung who had a thoracotomy. The client has a chest tube attached to a stationary closed chest drainage system. Health History Physical Assessment Vital Signs Nurses' Notes 1300: Arrived from the PACU. Alert and oriented × 3. Resting comfortably in bed, no restlessness. Closed chest tube drainage system intact. Upper tube is near the right front lung apex, occlusive dressing dry and intact. Lower tube on the right side near the base of the lung, occlusive dressing dry and intact. Drainage chamber = 70 mL red fluid. Water seal chamber = fluctuation of fluid, no bubbling. Suction control chamber = gentle bubbling. No subcutaneous emphysema. No shortness of breath or difficulty breathing. Lung sounds clear bilaterally. HOB elevated. Trachea midline. O2 2 L per NC. Having difficulty with coughing and deep breathing and using incentive spirometer. Pain 4/10.1400: Alert and oriented × 3. Reports nausea. Restless, states pain is 8/10. Closed chest tube drainage system intact. Occlusive dressings dry and intact. Drainage chamber = 170 mL red fluid. Water seal chamber = fluctuation of fluid with intermittent bubbling. Suction control chamber = gentle bubbling. No subcutaneous emphysema. States difficulty breathing due to pain. Lung sounds clear bilaterally. HOB elevated. Trachea midline. O2 2 L per NC. Refusing to cough and deep breathe or use incentive spirometer due to pain. Able to tolerate respiratory treatment with assistance of respiratory therapist. Nausea and pain medication administered as prescribed.1500: Sleepy but arousable. Restless, states nausea subsided, pain 7/10. Closed chest tube drainage system intact. Occlusive dressings dry and intact. Drainage chamber = 170 mL red fluid. Water seal chamber = continuous bubbling. Suction control chamber = gentle bubbling. Small amount subcutaneous emphysema around upper tube near the right front lung apex. States difficulty breathing. Lung sounds = crackles in lower lobes bilaterally. Trachea = slight deviation to the left. O2 2 L per NC. Refusing to cough and deep breathe. Vital Signs 1300 1400 1500 T 99.6°F (37.5°C) 100.4°F (38.0°C) 101.6 F (38.6°C) HR 88 BPM 96 BPM 110 BPM RR 18 bpm 22 bpm 26 bpm BP 100/62 mm Hg 128/88 mm Hg 140/90 mm Hg SpO2 94% on 2 L O2 per NC 92% on 2 L O2 per NC 90% on 2 L O2 per NC Click to indicate whether each nursing action listed below is either Indicated (appropriate or necessary) or Contraindicated (could be harmful)/Not Helpful) for the client’s plan of care at this time.

The nurse reviews the аdmissiоn nоte аnd vitаl signs fоr a 64-year-old client who was taken to the ED by a neighbor. 1455: Presented to the ED with report of increasing epigastric pain throughout the day. Pain started after dinner last night and usual medication did not help. States has been treated for gastroesophageal reflux disorder (GERD) for over 5 years with a variety of drugs, most recently omeprazole 40 mg orally twice a day. Other medications include:Ibuprofen 800 mg orally every morning for osteoarthritisAmlodipine 10 mg orally every day for hypertensionMVI 1 tab every day for general healthFamotidine 20 mg orally before meals PRN 1455:T 98ºF (36.7ºC)HR 82 BPMRR 18 bpmBP 152/88 mmHgSpO2 96% on RAPain level 6/10 on 0 to 10 pain scale Based on the medical record information, select 4 client findings that would be of immediate concern to the nurse.