Author Question: The nurse is to ambulate a patient who has an IV in his arm, an indwelling urinary catheter, and a ... (Read 106 times)

Mr. Wonderful · **on:** Jul 22, 2018

The nurse is to ambulate a patient who has an IV in his arm, an indwelling urinary catheter, and a chest tube. What action is appropriate for the nurse to take?

a. Hold the IV so it is higher than the patient's heart while ambulating.
b. Empty the urinary drainage tube before am-bulating.
c. Empty the closed chest drainage system before ambulating.
d. Hold the closed chest drainage system above the patient's chest level while ambulating.

Question 2

An elderly client admitted with pneumonia has a normal body temperature. The nurse realizes the reason for this inconsistency is that:

1. The client does not have pneumonia.
2. The client is losing body heat.
3. The room is cold.
4. The temperature is not a valid indicator of the pathology of the illness.

bigsis44 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
The closed chest drainage system must remain vertical at all times, including during transfers, to maintain the water seal. The IV should be placed on a portable pole and not held. The nurse should empty the urinary drainage bag before ambulating the patient because it reduces the weight of the bag.

Answer to Question 2

4. The temperature is not a valid indicator of the pathology of the illness.

Rationale:
Older adults' temperatures may not be a valid indication of the seriousness of the pathology of a disease. Other symptoms such as confusion and restlessness may be a more accurate indicator. A decrease in temperature does not indicate that the client does not have pneumonia. The client may or may not be losing body heat. It is not known whether the room is or is not cold.