A nurse is assisting in the care of a client.

Exhibits

Which of the following interventions should the nurse plan to implement? Select all that apply.

A. "Empty the collection chamber every 8 hr." The collection chamber should not be emptied on a regular schedule like every 8 hours. It should be emptied when it becomes full or according to facility policy. Regular monitoring of the chamber is essential to assess drainage and ensure it does not exceed capacity.
B. "Place the client in a supine position." The client should not be placed in a supine position when a chest tube is in place for a pneumothorax. The optimal position is typically sitting up or at least semi-Fowler’s position to facilitate lung expansion and drainage.
C. "Ensure the device is kept below the level of the client's chest." Keeping the chest tube drainage system below the level of the client’s chest is crucial for proper drainage and to prevent backflow of fluid or air. This position facilitates gravity drainage and helps maintain the effectiveness of the suction.
D. "Clamp the chest tube every 4 hr." Clamping the chest tube is generally not recommended unless specifically ordered by a healthcare provider. Clamping can lead to increased pressure in the pleural space and risk of tension pneumothorax. The nurse should avoid clamping unless there is a clear and appropriate reason to do so.

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.