A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

Wire cutters

Montgomery straps

Tracheostomy tray

Padded clamp

Answer and Explanation

The Correct Answer is D

A. Wire cutters:
Wire cutters are typically not necessary for postoperative care following a thoracotomy with chest tube placement. They are more commonly used in situations such as removing orthopedic hardware or cutting wires in emergency situations. Therefore, wire cutters are not essential equipment for this particular procedure.

B. Montgomery straps:
Montgomery straps are adhesive strips used to secure dressings or bandages without the need for tape. While they can be useful in some postoperative situations, they are not specifically required for a thoracotomy with chest tube placement.

C. Tracheostomy tray:

A tracheostomy tray contains equipment necessary for performing tracheostomy care, such as sterile gloves, tracheostomy tubes, and suctioning equipment. It is not directly related to thoracotomy or chest tube care post op.

D. Padded clamp:
A padded clamp, or chest tube holder, is a device used to secure chest tubes in place and prevent them from being accidentally dislodged. It is an essential piece of equipment for postoperative care following a thoracotomy with chest tube placement, as it helps maintain the integrity of the chest tubes and prevents complications such as air leaks or pneumothorax.

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Correct Answer is D, A, B, C.

Explanation

the correct sequence is D, A, B, C. Rationale: D (Mask self and the client): First, both the nurse and the client should wear masks to reduce the risk of infection during the procedure. A (Remove the old dressing): Next, the old dressing should be removed to expose the site. B (Create a sterile field): After removing the old dressing, a sterile field is created to maintain aseptic conditions. C (Apply precut gauze pads to the site): Finally, sterile precut gauze pads are applied to the site to protect the catheter.

A. Instruct a client on the use of an incentive spirometer. B. Insert an NG tube for a client who requires enteral feedings. C. Obtain a client's vital signs every 4 hr. D. Record a client's intake after each meal, E. Transfer a client to physical therapy.

Correct Answer is ["C","D","E"]

Explanation

C. Obtain a client's vital signs every 4 hr:
This task can typically be delegated to assistive personnel (AP) who have been trained and deemed competent in measuring vital signs. Routine monitoring of vital signs, such as temperature, pulse, respirations, and blood pressure, is within the scope of practice for AP and does not require the specialized skills of a licensed nurse.

D. Record a client's intake after each meal:
Assistive personnel can be delegated the task of recording a client's intake after each meal. This involves documenting the amount and type of food and fluids consumed by the client. While assessment of intake may involve some judgment, AP can be trained to perform this task accurately and consistently.

E. Transfer a client to physical therapy:
Assistive personnel can assist with transferring clients to physical therapy sessions. This may include tasks such as assisting clients into a wheelchair or onto a stretcher and accompanying them to the therapy area. While ensuring client safety during transfers is crucial, AP can perform these tasks under the direction and supervision of licensed nursing staff or physical therapists.

A. Instruct a client on the use of an incentive spirometer:
Teaching clients how to use medical equipment, such as an incentive spirometer, typically requires specialized knowledge and skills that fall within the scope of practice of licensed nursing staff. Therefore, this task should not be delegated to assistive personnel.

B. Insert an NG tube for a client who requires enteral feedings:
Inserting an NG tube is a specialized nursing skill that requires training, expertise, and an understanding of anatomy, proper technique, and potential complications. This task should only be performed by licensed nursing staff, such as registered nurses (RNs) or licensed practical nurses (LPNs), who have received appropriate education and training.

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A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

Nursing Test Bank

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Explanation

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