A nurse is caring for a client who has acute appendicitis and speaks a different language than the nurse. The client is scheduled to undergo an appendectomy. Which of the following actions should the nurse take? (Select all that apply.)

A. Place the client in a supine position: A supine position can impair lung expansion and increase the risk of respiratory complications. Clients with a chest tube are best positioned in a semi-Fowler’s or high-Fowler’s position to promote lung re-expansion and ease of breathing.

B. Empty the collection chamber every 8 hr: The collection chamber in a chest drainage system should not be emptied routinely, it should be emptied as needed to prevent it from overfilling. It is a closed system, and breaking it by emptying can introduce infection or disrupt the pressure needed for effective drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the chest drainage system below chest level uses gravity to promote drainage and prevents backflow of fluid or air into the pleural space. This positioning is essential to maintain the effectiveness and safety of the chest tube system.

D. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended as it can lead to a dangerous buildup of air (tension pneumothorax). Clamping is reserved for specific, short-term procedures under direct provider orders, such as changing the drainage system.

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.