NURSING 258 ACUTE CARE FINAL

A nurse is observing the closed chest drainage system of a client who is 24 hours post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. What action should the nurse take? - Continue to monitor the client’s respiratory status - (slow steady bubbling in the suction control chamber is an expected finding) A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the patients indwelling catheter has not drained in the past hour. What action would the nurse take first? - Check the tubing for kinks - (Use the least restrictive intervention first) A nurse in monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? - Heart rate - (When a clients circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement. A nurse in caring for a client who has cancer and a new prescription for odansetron tp treat chemotherapy induced nausea. Which of the following adverse effects should the nurse monitor? - Headache - (This is a common adverse effect of this medication) A nurse is caring for a client who has active pulmonary TB and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects? - Body secretions turning a red orange color - (Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.) A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? - Perform a neurovascular assessment - (The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check.") A nurse is caring for a client who is 1 day postop following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet and around the lips. For which of the following should the nurse assess the client? - Chvostek’s sign - The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia. A nurse is caring for a client who was admitted with bleeding esophageal varices and has a esophagogastric balloon Tamponade with sengstaken-blakeore tube to control the bleeding. What action should the nurse take? - Provide frequent oral and nares care - A client who has a Sengstaken-Blakemore tube in place is unable to swallow. If the client is alert, the nurse should encourage the client to spit saliva into a tissue or basin. If the client is not alert, gentle suctioning of the oral cavity and nares might be required to remove secretions.