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.

Choice A rationale:

Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.

Choice B rationale:

Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.

Choice C rationale:

Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.

Choice D rationale:

Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.

Choice E rationale:

Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.

• A. "I can take antacids at the same time as this medication.” This is generally incorrect. While antacids can provide quick relief, they can interfere with the absorption of pantoprazole. It's usually recommended to separate antacid use from pantoprazole by at least a couple of hours.
• B. "I will need to remain upright for 1 hour after taking the medication.” This is incorrect. This is a common instruction for general GERD management, but not specifically related to taking the pantoprazole medication itself.
• C. "I have to take this medication on an empty stomach.” This is generally correct. PPIs like pantoprazole work best when taken before meals, typically 30-60 minutes before breakfast. This allows the medication to be absorbed and ready to reduce acid production when you eat.
• D. "I should expect to have diarrhea while taking this medication.” While diarrhea can be a side effect of pantoprazole, it's not a guaranteed or expected outcome.