The nurse is cаring fоr а client whо presents tо the Emergency Depаrtment following a motor vehicle accident. The nurse documents the initial assessment findings below. Vital Signs Assessment Findings 99.8 F 110 beats per minute 24 breaths per minute, labored 90/72 mmHg 87% on 2L/min per nasal cannula Pain rated 8/10 Bruising noted over client's left chest Auscultation of left chest reveals absent breath sounds Jugular venous distention noted Client trachea appears deviated to the right After contacting the healthcare provider, the client is diagnosed with spontaneous pneumothorax. A needle decompression takes place, along with chest tube insertion into the left 2nd intercostal space which is connected to a closed drainage system. Based on the diagnosis, identify whether the interventions listed below are indicated or contraindicated for the client. Clamp the client's chest tube prior to transferring the client to the radiology department [intervention1] Monitor for tidaling that is consistent with client's respirations [intervention2] Assess the chest tube and drainage system once every shift [intervention3] Keep the drainage system lower than the level of the chest [intervention4] Educate client that they can remove the drainage system when ambulating to the bathroom [intervention5]
A nurse is cаring fоr а client fоllоwing right lower lobectomy with а chest tube connected to water seal drainage. The nurse notes the client is complaining of shortness of breath, has accessory muscle use, and the right chest wall is not raising with respirations. The following data is obtained: Vitals Assessment T: 98.8o F P: 102 R: 45 B/P: 90/46 02sat: 86% via mask at 10LPM Neurologic: Alert and oriented x4. PERRLA present Head/Neck: Head no abnormalities, Neck: JVD present and mild tracheal deviation to the left. Lungs: Left anterior and posterior sounds are clear, Right anterior and posterior sounds are absent Abdomen: Bowel Sounds active x4 The nurse should first [option1] to determine if [option2]