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?

The adolescent has not voided in 4 hr.

Rationale:

• A. The nurse should not address the parents' concerns and provide education and support, but refer the concerns to the provider to address the concerns about the surgical procedure.
• B. The adolescent's blood pressure is 131/89 mm Hg. This is not a correct answer because this blood pressure is within the normal range for an adolescent and does not indicate any complications or adverse effects from the injury or medication.
• C. The adolescent reports severe pain. This is not a correct answer because the nurse should administer morphine as prescribed for pain relief, but this is not a priority finding that requires immediate intervention or reporting to the provider. The nurse should also monitor the adolescent's pain level and response to medication, and use nonpharmacological methods to reduce pain and anxiety.
• D.Although this may raise concerns about renal injury, it is no a contraindication or cause for delay for the emergency surgical procedure.

- A. Correct. The nurse should turn off the CPM machine during mealtime to allow the client to eat comfortably and prevent aspiration.

- B. Incorrect. The nurse should maintain the client's affected hip in a neutral position to prevent dislocation of the prosthesis and promote healing.

- C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings for comfort, as this could interfere with the prescribed range of motion and speed of the device. The nurse should notify the provider if the client reports discomfort or pain.

- D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this could pose a safety hazard and damage the device. The nurse should place the CPM machine on a stable surface away from the bed.