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. Insert a rectal suppository: While a suppository can relieve constipation, abdominal distention after laparoscopic surgery is often caused by retained gas from insufflation rather than stool, so this intervention may not be effective.

B. Assist the client to ambulate: Early ambulation promotes peristalsis and helps the body expel retained carbon dioxide gas from the abdomen, which is a common cause of post-laparoscopic distention. This is a safe and effective first-line intervention.

C. Prepare the client for a paracentesis: Paracentesis is used to remove fluid in cases of ascites, not routine post-surgical gas-related distention. It is unnecessary for uncomplicated laparoscopic procedures.

D. Place the client in the prone position: While repositioning may offer some comfort, it does not significantly facilitate the expulsion of gas or reduce abdominal distention. Ambulation is more effective.

A. 0.45% sodium chloride B. Lactated Ringer's C. 0.9% sodium chloride D. 3% sodium chloride

Correct Answer is A

Explanation

Rationale:
A. 0.45% sodium chloride: This is a hypotonic solution that helps lower elevated serum sodium levels by promoting water movement into the intracellular space. It is appropriate for correcting hypernatremia gradually while preventing cerebral edema.

B. Lactated Ringer's: Lactated Ringer’s is an isotonic solution containing sodium, potassium, and calcium. It is not ideal for hypernatremia because its sodium content can maintain or worsen elevated serum sodium levels.

C. 0.9% sodium chloride: Normal saline is isotonic and contains a high concentration of sodium, which would not reduce hypernatremia and could exacerbate the condition if used for correction.

D. 3% sodium chloride: This hypertonic solution increases serum sodium levels and is used to treat hyponatremia, not hypernatremia. Administering it to a client with hypernatremia would worsen the electrolyte imbalance.

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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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