A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider? Select all that apply.
Mental confusion
Temperature
Heart rate
Urine output
Pain
Serum amylase level
Respiratory status
Sodium level
Cold, clammy skin
Blood pressure
Correct Answer : B,E
b. Ensure the chest tube remains below the level of the client's chest.
e. Reinforce loose dressing around the tube.
When managing a chest tube, it is important for the nurse to ensure that the chest tube remains below the level of the client's chest¹. This helps to prevent air from entering the pleural space and allows for proper drainage of fluid. The nurse should also reinforce any loose dressing around the tube to maintain a secure seal¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
During a mass casualty event, it is crucial for the nurse to assess and determine the acuity level (severity) and number of casualties who will be arriving at the healthcare facility. This information helps in planning and organizing resources, triaging patients based on their needs, and ensuring that appropriate care is provided to those who require immediate attention.
Delegating tasks to emergency health care specialists is a role that may be performed by a nurse in a leadership or supervisory position. However, the immediate priority for the nurse is to assess and triage incoming casualties.
Providing informational updates to members of the media is usually handled by designated spokespersons or communication specialists within the healthcare facility or incident command system. Nurses are primarily focused on patient care and should not be responsible for media communication during a mass casualty event.
Assisting in discharging stable clients to home is not directly related to the immediate response and care of casualties from a mass casualty event. The nurse's focus in such situations is primarily on the management of the incoming casualties and ensuring the availability of resources and care for those who require immediate attention.
Correct Answer is A
Explanation
Hepatitis A is primarily transmitted through the fecal-oral route, often due to contaminated food or water. However, it can also spread through close personal contact, including sharing towels, utensils, or other personal items. By using different hand towels than others in the home, the client demonstrates an understanding of the importance of preventing the transmission of the virus.
While hand hygiene is essential in preventing the spread of infectious diseases, including hepatitis A, alcohol-based cleansers are not effective against the hepatitis A virus. Washing hands with soap and water for at least 20 seconds is the recommended method to remove the virus from the hands.
Hepatitis A can be spread through contaminated food, so it is important for the client to avoid preparing food for others during the acute phase of the illness and until cleared by a healthcare professional.
Hepatitis A is not typically transmitted through contact with blood. It is primarily transmitted through the fecal-oral route or close personal contact with an infected individual.
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