A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

Choice A Reason:

Questioning the client about allergies before the procedure is appropriate. It is essential to assess the client for any allergies, especially to contrast dye, before the procedure. Allergic reactions to contrast dye can range from mild to severe, and prompt identification of potential allergies is crucial to prevent adverse reactions. If the client has a known allergy to the contrast dye, alternative imaging methods or pre-medication may be considered.

Choice B Reason:

Telling the client to increase fluid intake following the procedure is inappropriate. This instruction is relevant post-procedure for the elimination of the contrast dye from the body. However, it is not the priority at this moment, and the client's safety during the procedure takes precedence.

Choice C Reason:

Evaluating the client for claustrophobia is inappropriate. Assessing for claustrophobia is important, especially if the CT scan involves an enclosed space. However, this assessment can typically be conducted in advance of the procedure during the pre-procedure preparations.

Choice D Reason:

Informing the client about the steps of the procedure is inappropriate. Providing information about the procedure is important for the client's understanding and cooperation. However, ensuring the client's safety during the procedure by assessing for potential allergies to the contrast dye comes first.

Choice A Reason:

Placing the drainage system below the client's chest level is appropriate. This positioning allows for proper drainage and prevents the backflow of fluid or air into the chest. Maintaining the drainage system below the chest level helps ensure effective evacuation of air or fluid from the pleural space.

Choice B Reason:

Looping excess tubing next to the client's side is inappropriate. Looping excess tubing can create dependent loops, potentially causing fluid to accumulate in these areas and compromising the drainage system's effectiveness.

Choice C Reason:

Clamping the tubing when ambulating the client is inappropriate. Chest tube drainage systems should not be routinely clamped during ambulation. Clamping can lead to increased pleural pressure, potentially causing tension pneumothorax or other complications.

Choice D Reason:

Milking the client's tubing every shift is inappropriate. Milking or stripping the tubing is not recommended, as it can create a pressure gradient that may damage the lung tissue or disrupt the chest tube's seal. Passive drainage is preferred to maintain the negative pressure in the system.