Nokea
A client is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, what equipment should the nurse plan to have available at the bedside?
- A. Intubation tray
- B. Morphine sulfate injection
- C. Portable chest x -ray machine
- D. Chest tube and drainage system
Correct Answer: D
Rationale: Complications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse has a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. An intubation tray is not indicated. The client should be premedicated before the procedure, or a local anesthetic is used. A portable chest x -ray machine would be called for to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure.
You may also like to solve these questions
The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which should be the initial step in the process of change for the nurse manager?
- A. Plan strategies to implement the change.
- B. Set goals and priorities regarding the change process.
- C. Identify the inefficiency that needs improvement or correction.
- D. Identify potential solutions and strategies for the change process.
Correct Answer: C
Rationale: When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.
The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client states to the nurse in confidence that the family members frequently hit him. Which therapeutic statement should the nurse communicate in response?
- A. I have a legal obligation to report this type of abuse.
- B. Let's get these treated, and I will maintain confidence.
- C. Let's talk about ways to prevent someone from hitting you.
- D. If this happens again, you must call the emergency department.
Correct Answer: A
Rationale: The nurse should inform the client that nurses cannot maintain confidence about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options 3 and 4 delay protective action and place the client at risk for future abuse.
Wrist restraints have been prescribed for a client who is continuously pulling at the gastrostomy tube. The nurse develops a care plan and should determine that which findings would be negative outcomes related to the use of restraints? Select all that apply.
- A. The client is increasingly agitated.
- B. The client's left hand is pale and cold.
- C. The client's skin under the restraint is red.
- D. The client verbalizes the reason for the restraints.
- E. The client is unable to reach the gastrostomy tube with his or her hands.
- F. The client demonstrates behavior that includes biting the attending staff.
Correct Answer: A,B,C,F
Rationale: A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Negative outcomes in the use of restraints include signs of impaired skin integrity such as redness or skin breakdown; altered neurovascular status such as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; or injuring staff. Client verbalization of the reason for the restraints and the client's inability to reach the gastrostomy tube with his or her hands are expected outcomes.
A client has become physically aggressive toward staff and other clients. What action by the nurse will best assure the safety of the milieu while preserving the client's rights?
- A. Sedating the client
- B. Applying wrist restraints
- C. Contacting the client's primary health care provider
- D. Considering all possible alternative measures
Correct Answer: D
Rationale: Before applying restraints, the nurse must exhaust alternative measures to restraints such as a bed alarm, distraction, and a sitter. If the nurse determines that a restraint is necessary, its use is discussed with the client and family, and a prescription is obtained from the primary health care provider. The nurse should explain carefully to the client and family the indications for the restraint, the type of restraint selected, and the anticipated duration for its use. Sedation can be considered as a chemical restraint. The nurse avoids applying the restraint on a client who refused it to prevent client coercion and future charges of battery.
The nurse is planning a discharge teaching plan for a client who sustained a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan?
- A. Assisting the client to deal with long-term care placement
- B. Including the client's significant others in the teaching session
- C. Following up on laboratory and diagnostic tests that were prescribed
- D. Including information the primary health care provider has indicated
Correct Answer: B
Rationale: Involving the client's significant others in discharge teaching is a priority in planning for the client with a spinal cord injury. The client will need the support of the significant others. Knowledge and understanding of what to expect will help both the client and significant others deal with the client's limitations. Long-term placement is not the only option for a client with a spinal cord injury. Laboratory and diagnostic testing are not priority discharge instructions for this client. A primary health care provider's prescription is not necessary for discharge planning and teaching; this is an independent nursing action.