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.

Tracheostomy tray.

Montgomery straps.

Padded clamp.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Wire cutters are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Wire cutters are used for cutting wires and may be found in orthopedic or surgical trays, but they are not specifically required for thoracotomy care.

Choice B rationale:

A tracheostomy tray is not necessary for postoperative care following a thoracotomy with chest tube placement. Tracheostomy trays contain supplies for managing a tracheostomy, which is a procedure involving the creation of an opening in the neck to help with breathing. This procedure is not related to thoracotomy care.

Choice C rationale:

Montgomery straps are not necessary equipment for postoperative care after a thoracotomy with chest tube placement. Montgomery straps are used to secure dressings or bandages without adhesive tape. They are not typically used in thoracotomy care.

Choice D rationale:

A padded clamp is essential equipment for postoperative care after a thoracotomy with chest tube placement. The clamp is used to temporarily close or occlude the chest tube during transportation or when changing the drainage system. This prevents air from entering the pleural space, maintaining proper suction and preventing complications such as pneumothorax.

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Correct Answer is A

Explanation

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

A. Avoid including raw fruits in the client's diet. B. Restrict visits from young children to 2 hr per day. C. Measure the client's temperature once per shift. D. Use disposable gloves from a box outside the client's room.

Correct Answer is A

Explanation

- A. The nurse should discourage raw fruits due to risk of infection.

- B. There is no standard recommendation against exposure to young children.

- C. Incorrect. The nurse should measure the client's temperature at least every 4 hr, or more frequently if indicated because fever is a sign of infection in a client who has neutropenia and requires prompt intervention.

- D. Incorrect. The nurse should use disposable gloves from a box inside the client's room, not outside, to prevent cross-contamination and protect the client from exposure to pathogens.

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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?