A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.

Choice B reason: Administering PRN pain medication prior to transport is not the most important action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.

Choice C reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.

Choice D reason: This is the correct answer because keeping chest tube container below the site of insertion is the most important action for the nurse to take. Chest tube container is a device that collects air or fluid from the chest tube and maintains negative pressure in the pleural space or mediastinum. Keeping chest tube container below the site of insertion can prevent backflow of air or fluid into the chest cavity and maintain adequate drainage. If the chest tube container is raised above the site of insertion, it can cause tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and heart.

Choice A reason: This is a correct answer because obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a nursing action that can be assigned to the PN. Vital signs are measurements of the body's basic functions, such as temperature, pulse, blood pressure, and respiration. Vital signs should be monitored regularly after surgery to detect any signs of infection, bleeding, shock, or pain. The PN has the knowledge and skill to measure and record vital signs and report any abnormal findings to the nurse.

Choice B reason: This is a correct answer because performing daily surgical dressing change for a client who had an abdominal hysterectomy is a nursing action that can be assigned to the PN. Surgical dressing is a material that covers and protects a wound from infection, bleeding, or contamination. Surgical dressing should be changed daily or as needed to keep the wound clean and dry and promote healing. The PN has the knowledge and skill to perform surgical dressing change using sterile technique and appropriate equipment and report any signs of wound infection or dehiscence to the nurse.

Choice C reason: Initiating patient controlled analgesia (PCA) pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.

Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.

Choice E reason: This is a correct answer because monitoring a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM) is a nursing action that can be assigned to the PN. Warfarin is an anticoagulant medication that prevents blood clots by inhibiting vitamin K dependent clotting factors. Warfarin should be monitored per protocol by checking the international normalized ratio (INR), which measures how long it takes for blood to clot. The PN has the knowledge and skill to monitor warfarin per protocol by obtaining blood samples, performing point-of-care testing, and reporting results to the nurse.