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 {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices

• Evaluating the fetal heart rate tracing: The client presents with severe preeclampsia, as indicated by hypertension (166/110 mm Hg), 3+ proteinuria, and hyperreflexia. The priority is to assess fetal well-being since decreased fetal movement and maternal hypertension can compromise placental perfusion, placing the fetus at risk for hypoxia or distress.

• Administering magnesium sulfate IV: Once fetal assessment confirms stability, magnesium sulfate should be initiated to prevent eclamptic seizures. This medication stabilizes the central nervous system by reducing neuromuscular excitability and cerebral irritation associated with severe preeclampsia.

Rationale for Incorrect Choices

• Administering acetaminophen PO: The client already reported that acetaminophen was ineffective for headache relief. The headache is a sign of severe preeclampsia, not a benign pain complaint, so administering more acetaminophen does not address the underlying pathology.

• Obtaining 24-hour urine collection: While important for confirming the degree of proteinuria, this action is not an immediate priority. Stabilizing maternal and fetal conditions takes precedence over diagnostic collection.

• Inserting an indwelling urinary catheter: The catheter is required for strict intake and output monitoring during magnesium therapy, but it is not performed before ensuring fetal stability and initiating seizure prophylaxis.

• Administering betamethasone IM: Betamethasone promotes fetal lung maturity, which is appropriate in preterm conditions; however, it is not the immediate priority. Seizure prevention and fetal assessment are more urgent interventions at this stage.

A. Hypothermia B. Maternal diabetes C. Anemia D. Prematurity E. Thrombocytopenia

Correct Answer is ["A","B","D"]

Explanation

Rationale:
A. Hypothermia: Hypothermia increases metabolic demand and glucose utilization in newborns, making them more susceptible to hypoglycemia. Maintaining normal body temperature is crucial for preventing low blood glucose levels.

B. Maternal diabetes: Infants born to mothers with diabetes are at higher risk for hypoglycemia due to fetal hyperinsulinemia. After birth, the excess insulin can cause rapid drops in blood glucose.

C. Anemia: While anemia affects oxygen-carrying capacity, it is not a direct risk factor for neonatal hypoglycemia. Blood glucose regulation is not primarily impacted by red blood cell count.

D. Prematurity: Premature infants have limited glycogen stores and immature glucose regulation, increasing the risk for hypoglycemia. They may require closer glucose monitoring and early feeding interventions.

E. Thrombocytopenia: Low platelet count does not affect glucose metabolism and is not a recognized risk factor for neonatal hypoglycemia.

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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

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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