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 B

Explanation

Rationale:
A. "Purchasing more expensive items will improve quality health outcomes.": Higher cost does not necessarily correlate with better outcomes. Cost-effectiveness focuses on achieving optimal results while minimizing unnecessary expenses, not simply purchasing pricier items.

B. "Preventing readmissions will decrease overutilization of services.": Reducing hospital readmissions prevents unnecessary use of healthcare resources, lowers costs, and improves patient outcomes. Effective discharge planning, patient education, and follow-up care are strategies that support cost-effective care.

C. "Planning a 10-year budget will ensure cost-effective care.": Long-term budgeting aids financial planning but does not directly guarantee cost-effective care. Cost-effectiveness is achieved by evaluating interventions, resource utilization, and outcomes continuously.

D. "Hiring travel nurses is an effective method of cost containment.": Travel nurses typically have higher hourly rates than permanent staff, which can increase costs. While they provide staffing flexibility, this strategy is not considered cost-effective for routine staffing needs.

A. Bradycardia B. Abdominal pain C. Hypertension D. Hydramnios

Correct Answer is B

Explanation

Rationale:
A. Bradycardia: Ectopic pregnancy does not typically cause bradycardia. If cardiovascular changes occur, tachycardia is more common due to pain, blood loss, or hypovolemic shock in the event of rupture.

B. Abdominal pain: Abdominal or pelvic pain is a hallmark sign of ectopic pregnancy. Pain may be localized to one side, often corresponding to the site of implantation, and can become severe if tubal rupture occurs.

C. Hypertension: Hypertension is not associated with ectopic pregnancy. Blood pressure may decrease if significant internal bleeding occurs, potentially leading to hypotensive shock.

D. Hydramnios: Hydramnios (excess amniotic fluid) occurs in certain intrauterine complications but is not a feature of ectopic pregnancy, as the gestation occurs outside the uterine cavity.

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