A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?

Choice A Reason:
Vigorously strip the chest tube twice daily. The nurse should clarify the prescription to "vigorously strip the chest tube twice daily" with the provider. Stripping or milking a chest tube is generally not recommended, as it can cause damage to the tube and lead to complications. The movement of fluid and air in the chest tube should be allowed to occur naturally based on the patient's own respiratory effort.

Choice B Reason:

Assist the client out of bed three times daily - This is a reasonable activity for a client with a chest tube, as mobility and deep breathing can help prevent complications.

Choice C Reason:

Notify the provider when tiddling ceases - Monitoring for tiddling (fluctuations in the water seal chamber with respiration) and notifying the provider when tiddling stops is important, as it might indicate a potential issue with the chest tube placement or functioning.

Choice D Reason:

Administer morphine 2 mg IV bolus every 3 hr PRN for pain - Administering pain relief for the client is appropriate and helps manage their comfort. Pain control is important to encourage deep breathing and prevent complications related to shallow breathing due to pain.

Choice A Reason:

Gently massage the area around the client's incision is not recommendable. Massage may not be suitable for a recently operated area and could potentially worsen pain and disrupt the healing process.

Choice B Reason:

Apply an ice pack to the client's knee is recommendable. Applying an ice pack to the client's knee can help reduce pain and inflammation following a total knee arthroplasty. Ice can help numb the area and reduce swelling, providing relief to the client's discomfort. It's important to use a barrier, such as a cloth or towel, between the ice pack and the skin to prevent frostbite.

Choice C Reason:

Perform range-of-motion exercises to the client's knee is not recommendable. Range-of-motion exercises may be beneficial for recovery, but they might not be appropriate at this pain level. Pain should be managed before engaging in such activities.

Choice D Reason:

Place pillows under the client's knee is recommendable. Elevating the knee might help with comfort, but addressing the pain directly should be the priority.