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 D

Explanation

Rationale:
A. "I understand that my scars will eventually fade.": This statement reflects acceptance and understanding of the healing process rather than distress about appearance. It indicates the client is cognitively processing changes without expressing body image disturbance.

B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group demonstrates coping and adjustment. The client is seeking social and emotional support, which is a healthy response to surgery rather than a sign of altered body image.

C. "I want to have reconstructive surgery as soon as I can.": Desire for reconstructive surgery is a proactive coping strategy and a way to regain body image control. It reflects planning for recovery rather than expressing negative feelings about current body changes.

D. "I prefer to leave the lights off when I am changing my clothes.": Avoiding exposure of the body and seeking darkness when changing clothes indicates discomfort and distress with physical appearance. This behavior reflects an altered body image and difficulty accepting the changes after surgery.

A. Guide the client by walking parallel with them. B. Rearrange clients bedside table items frequently. C. Remove objects from client's path to the bathroom. D. Use a loud tone of voice when speaking with the client.

Correct Answer is C

Explanation

Rationale:
A. Guide the client by walking parallel with them: Clients with visual impairment should be guided by walking slightly ahead of them, allowing them to hold the nurse’s arm and follow safely. Walking parallel can limit spatial awareness and increase the risk of collision or falls.

B. Rearrange clients bedside table items frequently: Frequently moving personal items can confuse a client with reduced vision and increase the risk of injury. Maintaining a consistent environment promotes independence and safety.

C. Remove objects from client's path to the bathroom: Clearing pathways reduces the risk of trips and falls, which is essential for clients with impaired vision. Ensuring a clutter-free environment is a key safety intervention in the plan of care.

D. Use a loud tone of voice when speaking with the client: A louder voice is unnecessary unless the client has a hearing impairment. Communication should focus on clear, descriptive verbal guidance rather than volume, emphasizing orientation and safety.

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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.)

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Naxlex Comprehensive Predictor Exams

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