A nurse is assisting in the care of a client.

Admission Assessment.

1500: Client transferred from postanesthesia care unit, following a left lung lobectomy.

Client alert and oriented to person, place, time,. and situation.

Reports pain as 3 on a scale of 0 to 10. Dressing dry and intact to left chest.

Water seal chest tube drainage system has 100 mL sanguineous drainage.

Right lung sounds clear.

Left lung sounds diminished.

For each potential nursing action, click to specify if the potential action is. indicated or contraindicated for the client who has a chest tube.

The correct answer is choice b. Charge nurse.

Choice b rationale: The charge nurse is the appropriate personnel to report the incorrect blood glucose monitoring by the assistive personnel. As the nurse in charge of the unit, the charge nurse has the authority and responsibility to address issues related to patient care and ensure that nursing staff, including assistive personnel, are providing care according to facility policies and procedures

Choice a rationale: While the nurse manager is responsible for overseeing the nursing staff and ensuring quality patient care, it is more appropriate to report the incident to the charge nurse first, as they are directly responsible for the unit and can immediately address the issue

Choice c rationale: The risk manager is responsible for identifying, assessing, and mitigating risks within the healthcare facility. While the incorrect blood glucose monitoring could be considered a risk, it is not the primary role of the risk manager to address issues related to patient care. The charge nurse is better positioned to address the immediate concern and ensure proper training or corrective action for the assistive personnel.

Choice d rationale: The nurse supervisor is responsible for overseeing and managing nursing staff, similar to the nurse manager. However, the charge nurse is the more appropriate personnel to report the incident to, as they are directly responsible for the unit and can immediately address the issue

Choice A rationale:

"Apply fundal pressure during contractions." - Applying fundal pressure during contractions is not appropriate during the latent stage of labor. Fundal pressure is typically used during the second stage of labor (active pushing phase) to assist with fetal descent. Using it during the latent stage can be harmful.

Choice B rationale:

"Encourage the client to soak in a hot bath." - Soaking in a hot bath is generally not recommended during labor, especially without specific indications. It is essential to maintain the safety and well-being of both the mother and the baby. Encouraging the client to change positions or use comfort measures like relaxation techniques would be more appropriate.

Choice C rationale:

"Instruct the client to change positions frequently." - This is the correct answer. During the latent stage of labor, encouraging the client to change positions frequently can help promote comfort and optimize fetal positioning. Changing positions can reduce discomfort, enhance uterine contractions, and facilitate the progression of labor.

Choice D rationale:

"Tell the client to push during contractions." - Pushing during contractions is typically reserved for the second stage of labor when the cervix is fully dilated. In the latent stage, the cervix is not fully dilated, and pushing prematurely can be harmful and delay labor progress. It is essential to follow the appropriate guidelines for each stage of labor.