A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

Clamp the chest tube every 4 hr.

Place the client in a supine position.

Ensure the device is kept below the level of the client's chest.

Empty the collection chamber every 8 hr.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Clamp the chest tube every 4 hr: Routine clamping of a chest tube is not recommended, as it can lead to tension pneumothorax by trapping air in the pleural space. Clamping is only done briefly and for specific reasons, such as system checks or before removal.

B. Place the client in a supine position: The supine position can impair lung expansion and hinder drainage from the pleural space. Clients with a chest tube are best positioned in semi-Fowler’s or high-Fowler’s to promote ventilation and facilitate drainage.

C. Ensure the device is kept below the level of the client's chest: Keeping the drainage system below chest level promotes gravity-assisted drainage and prevents backflow of air or fluid into the pleural space, which could compromise lung re-expansion.

D. Empty the collection chamber every 8 hr: The collection chamber is not emptied; it is replaced when full. Opening the system introduces infection risk and disrupts the closed drainage system necessary for maintaining negative pressure.

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Correct Answer is D

Explanation

Rationale:

A. Boggy fundus 3 fingerbreadths above the umbilicus: A boggy uterus located above the umbilicus suggests uterine atony, which indicates that the oxytocin may not have been effective. This finding is not expected 30 minutes after administering oxytocin.

B. Client report of burning with urination: Burning during urination is unrelated to oxytocin administration and may point toward a urinary tract infection. It does not reflect the expected physiological response to uterine stimulation for controlling postpartum hemorrhage.

C. Saturation of perineal pad in 15 min: Continued excessive bleeding despite oxytocin administration indicates treatment failure and requires immediate intervention. Oxytocin should reduce uterine bleeding; thus, ongoing hemorrhage is not an expected finding.

D. Client report of uterine cramping: Uterine cramping is an expected response to oxytocin, which works by stimulating uterine smooth muscle contractions. These cramps help compress blood vessels at the placental site, reducing postpartum bleeding and promoting involution.

A. Urinary retention B. Restlessness C. Difficulty swallowing D. Constipation

Correct Answer is B

Explanation

Rationale:

A. Urinary retention: Urinary retention is a potential side effect of epidural anesthesia due to blockade of sacral nerves, not necessarily a sign of unrelieved pain. It may occur even if pain is well managed, especially with regional anesthetics affecting bladder function.

B. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain. When verbal reporting is limited or unreliable, restlessness may reflect discomfort, agitation, or anxiety related to inadequate pain control following procedures such as epidural administration.

C. Difficulty swallowing: Difficulty swallowing is not associated with pain from a herniated disc or the effects of an epidural. It may instead suggest upper airway or neurologic issues and should prompt assessment for complications unrelated to pain control.

D. Constipation: Constipation is more commonly linked to opioid use or immobility rather than unrelieved pain. While discomfort may contribute, constipation alone does not reliably indicate the adequacy of pain relief in clients receiving an epidural.

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A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

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