Author Question: A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths ... (Read 94 times)

AEWBW · **on:** Jun 25, 2018

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?

a. Ambulate the client in the hallway to promote deep breathing.
b. Auscultate the client's anterior and posterior lung fields.
c. Encourage the client to take shallow breaths to help with the pain.
d. Administer pain medication and encourage the client to take deep breaths.

Question 2

A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit?

a. Instruct the client to wash his or her hands after contact with other people.
b. Implement Droplet Precautions and don a surgical mask.
c. Keep the client isolated from other clients with cystic fibrosis.
d. Obtain blood, sputum, and urine culture specimens.

Animal_Goddess · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client's discomfort and need to take deep breaths to prevent complications.

Answer to Question 2

ANS: C
Burkholderia cepacia infection is spread through casual contact between cystic fibrosis clients, thus the need for these clients to be separated from one another. Strict isolation measures will not be necessary. Although the client should wash his or her hands frequently, the most important measure that can be implemented on the unit is isolation of the client from other clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum, and urine culture specimens will not provide information necessary to care for a client with Burkholderia cepacia infection.