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 C
Explanation
A.While increasing dietary fiber can help with constipation, a common side effect of iron supplements, it does not directly improve the absorption of the medication
B.Berries and citrus fruits, on the other hand, are good sources of vitamin C, which can actually enhance iron absorption. Therefore, eliminating them from the diet would not be beneficial for improving iron absorption.
C.The recommendation the nurse should make to improve the absorption of the iron supplement (ferrous sulfate) is to avoid drinking milk with the medication. Calcium in milk can interfere with the absorption of iron, so it is best to separate the consumption of these two substances.
D.Green tea contains compounds called tannins, which can interfere with iron absorption. Therefore, it is not recommended to take iron supplements with green tea.
Correct Answer is A
Explanation
a. Support the client's decision to stop the treatment.
As a nurse, it is important to respect the client's autonomy and right to make decisions about their own care. The decision to stop dialysis treatment is a personal one and should be respected by the healthcare team. The nurse should support the client's decision and provide information and resources to help the client manage symptoms and maintain comfort during the end-of-life process.
It is not appropriate for the nurse to suggest that the client discuss the decision with her family or to discuss alternative treatment methods, as these decisions should be made by the client in conjunction with their healthcare provider.
It may be appropriate to offer spiritual or emotional support to the client, but this should be based on the client's preferences and not imposed upon them by the healthcare team.
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