A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Clamp the chest tube every 2 hr to assess the amount of drainage.

Maintain the collection chamber above the level of the client's waist.

Strip the chest tube vigorously to dislodge blood clots.

Add water to the water seal chamber as it evaporates.

Mark the drainage output on the collection chamber.

Answer and Explanation

Correct Answer : D,E

Rationale:
A. Clamp the chest tube every 2 hr to assess the amount of drainage: Routine clamping of a chest tube is unsafe because it can cause a sudden buildup of pressure in the pleural space, leading to a tension pneumothorax.

B. Maintain the collection chamber above the level of the client's waist: The collection chamber should always be positioned below the level of the client’s chest to allow gravity drainage. Placing it above the waist would prevent proper drainage.

C. Strip the chest tube vigorously to dislodge blood clots: Vigorous stripping or milking of the chest tube can create excessive negative pressure, potentially damaging lung tissue. Current guidelines recommend gentle milking only if ordered and rarely if obstruction is suspected.

D. Add water to the water seal chamber as it evaporates: Maintaining the proper water level in the water seal chamber is essential to preserve the one-way valve function that prevents air from re-entering the pleural space. Evaporation can reduce the seal, so the nurse should routinely check and refill it.

E. Mark the drainage output on the collection chamber: Documenting drainage at regular intervals allows accurate monitoring of the client’s progress and early identification of complications such as increased bleeding or fluid accumulation. It supports timely communication with the healthcare provider.

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Correct Answer is ["C","D"]

Explanation

Rationale for Correct Choices

• Intravenous antibiotic: The client shows classic signs of postpartum endometritis, including fever, uterine tenderness, boggy fundus, and foul-smelling lochia. IV antibiotics are the primary treatment to target the uterine infection and prevent progression or sepsis.

• Increase in daily fluid intake: Adequate hydration supports circulation, helps maintain uterine tone, and assists in reducing the risk of complications such as hypotension or dehydration from infection. Fluids also support antibiotic therapy by promoting renal clearance and overall recovery.

Rationale for Incorrect Choices

• Kleihauer-Betke test: This test identifies fetal-to-maternal hemorrhage, which is not indicated here because the client’s hemoglobin is stable and there is no evidence of significant postpartum hemorrhage.

• Tocolytic medication: Tocolytics are used to suppress preterm labor, which is irrelevant for this postpartum client whose uterus has already delivered the fetus.

• Intrauterine tamponade balloon: This intervention is used for severe postpartum hemorrhage to mechanically control bleeding. The client’s bleeding is moderate and the uterus is firm after massage, so this is not indicated at this time.

Correct Answer is []

Explanation

Rationale for Correct Choices

• Heart failure: The client has classic signs of heart failure, including S3 heart sound, bilateral crackles, lower extremity edema, elevated BNP, and cool extremities, indicating fluid overload and decreased cardiac output. Early identification allows timely interventions to prevent decompensation.

• Obtain a prescription for a diuretic: Diuretics reduce fluid retention, alleviate pulmonary congestion, and improve oxygenation. Administering a diuretic helps manage the client’s edema, dyspnea, and fatigue, reducing cardiac workload.

• Educate the client about sodium restriction : Limiting dietary sodium prevents further fluid retention and helps control blood pressure, reducing the risk of exacerbating heart failure symptoms and hospital readmission.

• Blood pressure: Monitoring BP is essential in heart failure to detect hypotension from decreased cardiac output or over-diuresis. Maintaining safe BP ensures adequate perfusion and guides treatment adjustments.

• Daily weight: Daily weights are a sensitive measure of fluid status. Rapid increases indicate fluid accumulation, allowing early interventions with diuretics or fluid management to prevent worsening heart failure.

Rationale for Incorrect Choices

• Aortic stenosis: Aortic stenosis primarily causes systolic murmur, angina, syncope, and sometimes heart failure over time. This client’s presentation is dominated by fluid overload and elevated BNP, with no auscultatory evidence of stenotic valve disease.

• Endocarditis : Endocarditis is associated with fever, positive blood cultures, heart murmurs, and skin lesions like Janeway lesions or Osler nodes. This client has no signs of infection, making endocarditis unlikely.

• Mitral stenosis : Mitral stenosis produces a diastolic murmur, pulmonary congestion, and sometimes atrial fibrillation. While some pulmonary signs may overlap with heart failure, this client lacks the characteristic murmur and risk factors for mitral stenosis.

• Prepare the client for cardioversion : Cardioversion is indicated for arrhythmias such as atrial fibrillation with rapid ventricular response. The client’s heart rhythm is regular, making this action unnecessary.

• Administer antibiotics as prescribed : Antibiotics are used for infections such as endocarditis or sepsis. This client has no fever, abnormal labs, or signs of systemic infection, so antibiotics are not indicated.

• Educate the client about valve replacement : Valve replacement education is relevant only if the client has significant valvular disease. This client’s data show no evidence of aortic or mitral valve pathology, so this action is not needed.

• Fever : Monitoring for fever is critical in infection or sepsis. Since the client’s temperature is normal, this is not an immediate concern.

• Blood cultures : Blood cultures identify bacteremia or endocarditis. The client has no infection indicators; therefore, this parameter is unnecessary.

• Skin lesions : Skin lesions such as Osler nodes or Janeway lesions indicate infective endocarditis. The client shows no such lesions, making monitoring irrelevant in this scenario.

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A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D"]

Explanation

Correct Answer is []

Explanation

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