A nurse is caring for a client who is 1 day postoperative fo…
A nurse is caring for a client who is 1 day postoperative following a right-sided thoracotomy with a chest tube insertion. Nurses Notes 0800: Chest tube is patent to client’s right side, dressing is dry and intact, connected to a disposable three-chamber drainage system. Suction at prescribed -20 cm H2O. Tidaling noted in the water seal chamber along with continuous bubbling. Client reports pain as 3 on a scale of 0 to 10. 50 mL of sanguineous drainage noted in the collection chamber since 0700. Productive cough with clear sputum. Physical Examination 0800: Lung sounds diminished in the bases bilateral, no adventitious sounds noted; Bowel sounds active x 4 quadrants, abdomen soft; Capillary refill less than 2 seconds; Skin dry and intact, 1+ edema noted to legs bilaterally Diagnostic Results 0500: CBC – H&H 15 g/dL, 35%; WBC count – 9,500/mm3 (5,000 to 10,000/mm3) Vital Signs 0800: Temp – 37.2° C (99° F); HR – 92/min; RR – 20/min; BP – 128/68 mm Hg; SaO2 96% on 2 L O2 via nasal cannula ***A nurse prioritizes care after completing the assessment and initiates the following action. Match the following: Condition the client is most likely experiencing, 2 actions the nurse should take to address that condition 2 parameters the nurse should monitor to assess the client’s progress.
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