A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

Place the client in high-Fowler's position.

Obtain the client's vital signs.

Administer heparin to the client.

Encourage the client to cough and deep breathe.

Answer and Explanation

The Correct Answer is A

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Correct Answer is C

Explanation

The correct answer is choice C. Lime ice popsicle.

Choice A rationale:

Orange juice is acidic and can irritate the stomach lining, which is not ideal for someone recovering from gastroenteritis.Acidic foods and drinks can exacerbate symptoms like nausea and stomach pain.

Choice B rationale:

Cream of broccoli soup is not recommended because it is a dairy-based product.Dairy can be difficult to digest and may worsen symptoms like diarrhea and stomach cramps during the recovery phase of gastroenteritis.

Choice C rationale:

Lime ice popsicle is a good choice because it is a clear liquid that can help with hydration and is easy on the stomach.Ice popsicles can also help soothe the throat and provide a small amount of sugar for energy without overwhelming the digestive system.

Choice D rationale:

Vanilla pudding, although soft, contains dairy, which can be hard to digest for someone recovering from gastroenteritis.Dairy products can lead to further gastrointestinal discomfort.

A. Monitor for at least 150 mL of drainage every hour. B. Clamp the tube for 30 min every 8 hr. C. Pin the tubing to the client's bed sheets. D. Replace the unit when the drainage chamber is full.

Correct Answer is A

Explanation

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

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A nurse is assisting in the care of a client who has a pulmonary embolism and is experiencing dyspnea. Which of the following actions should the nurse take first?

Nursing Test Bank

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