A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Choice A rationale:

Limiting the use of familiar objects is not recommended for clients with Alzheimer's disease. Familiar objects can provide comfort and security to these clients and help them maintain a sense of familiarity in their environment.

Choice B rationale:

Making a schedule of daily tasks is a helpful intervention for clients with Alzheimer's disease. Routine and structure can reduce frustration and anxiety in clients with cognitive impairment by providing predictability and a sense of purpose.

Choice C rationale:

Having several family members visit daily may be overwhelming for the client with Alzheimer's disease, leading to increased confusion and agitation. It is essential to balance social interaction with the client's comfort level and needs.

Choice D rationale:

Asking questions that require more than one answer can be confusing for clients with Alzheimer's disease. s should be simple and straightforward to enhance understanding and communication.

Clamp chest tube when client ambulates. Contraindicated. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition. The chest tube should be kept open and patent at all times, unless ordered by the provider for a specific reason. Report burning pain in chest to provider. Indicated.

Burning pain in the chest may indicate an infection, inflammation, or injury to the pleura or lung tissue. The provider should be notified of any changes in the client’s pain or discomfort.

Reinforce dressing around the tube as needed if it loosens. Indicated. The dressing around the chest tube should be kept dry and intact to prevent air leaks and infection. If the dressing becomes loose, wet, or soiled, it should be reinforced with sterile gauze and tape.

Strip the tubing twice daily to ensure patency. Contraindicated. Stripping or milking the tubing can cause increased negative pressure in the chest cavity, which can damage the lung tissue and impair gas exchange. The tubing should be assessed for kinks, clots, or obstructions, and gently tapped or repositioned if needed.

Maintain chest tube below the chest. Indicated. The chest tube should be kept below the level of the chest to facilitate drainage by gravity and prevent backflow of fluid into the pleural space.