A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

A. Clamping the chest tubes is contraindicated because it can lead to tension pneumothorax, a life- threatening condition where air accumulates in the pleural space under pressure. If the chest tube becomes disconnected, the nurse should immediately place the end of the tube in sterile water to maintain the water seal and prevent air from entering the pleural space.
B. The drainage container must always be kept below the level of the client's chest. This position allows gravity to facilitate drainage from the pleural space into the collection chamber. If the container is positioned above the client's chest, drainage could potentially flow back into the pleural space, leading to complications.
C. It is essential to monitor and record the amount and characteristics of drainage regularly. Emptying the collection container at least once every shift ensures accurate measurement of drainage output and helps in assessing the client's response to treatment.
D. The water-seal chamber of the chest drainage system maintains the desired amount of suction (usually
-20 cm H2O) to facilitate lung re-expansion. This chamber should be filled with sterile water to the recommended level, usually marked on the device. Adding tap water can introduce contaminants and should be avoided.

A. Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B. A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C. Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D. Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.