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 D
Explanation
a.Frequent bathing can actually worsen dry, itchy skin as it can strip away the natural oils that help moisturize the skin. Instead, the nurse should encourage the client to limit bathing to shorter durations using lukewarm water and gentle, fragrance-free cleansers.
b.Powder may not provide significant relief for dry, itchy skin and can potentially irritate the skin further. It is best to focus on moisturizing and hydrating the skin to alleviate the symptoms.
c.While this might seem helpful, oils in the bath can create a slippery surface, posing a fall risk, especially for older adults. Additionally, oils might not provide sufficient hydration to the skin and could leave a residue that is not always beneficial.
d.Dry, itchy skin is a common concern among older adults, and it can be exacerbated by low humidity levels. Placing a humidifier in the client's room helps to increase the moisture content in the air, which can alleviate dryness and itchiness. The increased humidity can help prevent the skin from becoming overly dry and can provide relief from the symptoms.
Correct Answer is B
Explanation
Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.
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