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 A

Explanation

Rationale:
A. Initiate fibrinolytic therapy: Fibrinolytic therapy, such as tissue plasminogen activator (tPA), is most effective when administered within a 3- to 4.5-hour window from the onset of ischemic stroke symptoms. Early administration can dissolve the clot, restore cerebral blood flow, and improve neurological outcomes.

B. Place the client in a supine position: Clients with ischemic stroke are usually positioned with the head of the bed elevated 15–30 degrees unless contraindicated. Supine positioning can increase intracranial pressure and risk aspiration, which may worsen neurological status.

C. Prepare the client for a chest x-ray: A chest x-ray is not a priority in acute ischemic stroke management. Immediate neuroimaging, typically a CT scan, is required to differentiate ischemic from hemorrhagic stroke before initiating fibrinolytic therapy.

D. Insert an indwelling urinary catheter: Inserting a catheter is not indicated as an initial intervention for acute stroke unless the client is unable to void or requires strict output monitoring. Priority actions focus on neuroprotection and reperfusion therapy.

A. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³) B. Temperature 36.8° C (98° F) C. Body mass index of 32 D. Blood glucose 90 mg/dL (74 to 106 mg/dL)

Correct Answer is C

Explanation

Rationale:
A. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): A normal white blood cell count indicates that the body is not currently mounting an inflammatory or infectious response. This finding does not place the client at risk for developing a wound infection.

B. Temperature 36.8° C (98° F): A normal temperature suggests that the client is afebrile and not showing signs of infection or systemic inflammation. This finding reflects stable postoperative recovery and is not a risk factor for infection.

C. Body mass index of 32: Obesity increases the risk for surgical wound infection because excess adipose tissue has poor blood supply, impairing oxygen and nutrient delivery needed for wound healing. Additionally, increased tension on the incision site can lead to dehiscence and bacterial colonization.

D. Blood glucose 90 mg/dL (74 to 106 mg/dL): A normal blood glucose level supports effective immune function and normal wound healing. Hyperglycemia, not euglycemia, would predispose the client to infection by impairing leukocyte function.

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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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