A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

Rationale:

A. Use passive listening techniques during conflict resolution: Passive listening involves minimal engagement and can lead to misunderstandings or missed key concerns. Active listening is more effective in conflict resolution as it validates feelings and clarifies perspectives.

B. Ask closed-ended questions about the conflict: Closed-ended questions limit the depth of responses and may not fully uncover the underlying issues. Open-ended questions encourage dialogue and help reveal the root causes of conflict more effectively.

C. Ensure each individual can respond defensively about the conflict: Allowing or encouraging defensive responses can escalate tension and hinder resolution. A nonjudgmental and respectful environment promotes open communication and constructive problem-solving.

D. Gather individual information regarding the conflict: Collecting information from each party separately allows the nurse manager to understand different perspectives, identify miscommunications, and develop a balanced and informed approach to resolving the conflict.

Rationale:

A. Clamp the chest tube every 2 hr to assess the amount of drainage: Clamping a chest tube is not routine and can lead to tension pneumothorax by preventing air or fluid from escaping the pleural space. It should only be done briefly and under specific provider direction.

B. Add water to the water seal chamber as it evaporates: Water in the water seal chamber may evaporate over time and should be maintained at the prescribed level to preserve the one-way seal. This ensures proper functioning of the chest drainage system.

C. Mark the drainage output on the collection chamber: Marking the drainage level at regular intervals allows for accurate monitoring of output trends, which can help detect complications like hemorrhage or increased fluid accumulation.

D. Maintain the collection chamber above the level of the client's waist: The collection chamber should be kept below the level of the chest to promote gravity drainage. Elevating it above the waist can allow fluid or air to flow back into the pleural space.

E. Strip the chest tube vigorously to dislodge blood clots: Stripping is not recommended as it creates high negative pressure that may damage lung tissue. If clots are suspected, milking the tube gently or other interventions should be discussed with the provider.