A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?

Choice A Reason:
Replace the unit when the drainage chamber is full is correct. Regularly emptying the drainage chamber when it becomes full is essential to ensure the drainage system functions properly and continues to effectively remove fluids or air from the chest cavity.

Choice B Reason:
Clamp the tube for 30 min every 8 hr. is incorrect.
Clamping a chest tube without a specific medical order or indication can lead to complications such as a buildup of pressure within the chest cavity or potential damage to the lungs. It's generally not a routine action to clamp the tube without proper instruction.

Choice C Reason:
Pin the tubing to the client's bed sheets is incorrect. Pinning the tubing to the bed sheets can cause tension on the chest tube, leading to accidental dislodgment or obstruction. The tubing should be secured but not pinned to prevent inadvertent movement.

Choice D Reason:
Monitor for at least 150 mL of drainage every hour is incorrect. There isn't a standard or prescribed amount of drainage that should occur hourly. The nurse should monitor the drainage rate and characteristics but shouldn't expect a specific volume within a set timeframe. Monitoring for excessive or decreased drainage and changes in characteristics is crucial, but an hourly volume expectation isn't appropriate.

Choice A Reason:

Keeping both arms below the level of the client's heart doesn't specifically address the prevention of lymphedema and might not be necessary for this purpose.

Choice B Reason:

Limiting range-of-motion exercises with the affected arm could potentially contribute to stiffness and reduced function, but appropriate and gradual range-of-motion exercises are generally recommended to prevent lymphedema.

Choice C Reason:

Using the client's left arm to obtain blood samples is correct. Lymphedema can occur due to the disruption of lymphatic vessels during surgery, leading to the accumulation of lymph fluid. To reduce the risk of lymphedema, medical procedures or blood draws should typically avoid using the affected arm. In this case, after a right radical mastectomy, using the left arm for blood samples can help protect the compromised lymphatic system in the right arm.

Choice D Reason:

Obtaining blood pressure readings using the client's right arm is not directly related to preventing lymphedema. However, excessive pressure or trauma to the affected arm should generally be avoided to reduce the risk of lymphedema.