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.

Add water to the water seal chamber as it evaporates.

Mark the drainage output on the collection chamber.

Maintain the collection chamber above the level of the client's waist.

Strip the chest tube vigorously to dislodge blood clots.

Answer and Explanation

Correct Answer : B,C

Rationale:

A. Clamp the chest tube every 2 hr to assess the amount of drainage: Clamping a chest tube is not routine and can lead to tension pneumothorax by preventing air or fluid from escaping the pleural space. It should only be done briefly and under specific provider direction.

B. Add water to the water seal chamber as it evaporates: Water in the water seal chamber may evaporate over time and should be maintained at the prescribed level to preserve the one-way seal. This ensures proper functioning of the chest drainage system.

C. Mark the drainage output on the collection chamber: Marking the drainage level at regular intervals allows for accurate monitoring of output trends, which can help detect complications like hemorrhage or increased fluid accumulation.

D. Maintain the collection chamber above the level of the client's waist: The collection chamber should be kept below the level of the chest to promote gravity drainage. Elevating it above the waist can allow fluid or air to flow back into the pleural space.

E. Strip the chest tube vigorously to dislodge blood clots: Stripping is not recommended as it creates high negative pressure that may damage lung tissue. If clots are suspected, milking the tube gently or other interventions should be discussed with the provider.

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Correct Answer is A

Explanation

Rationale:

A. "Tell me more about how you are feeling about this pregnancy.": This open-ended, therapeutic statement encourages the adolescent to express her thoughts and emotions. It shows empathy and supports trust-building, which is essential in managing anxiety and promoting emotional well-being.

B. "Clients are usually happy about a second pregnancy.": This response generalizes experiences and dismisses the client’s individual feelings. It may cause the client to feel misunderstood or pressured to conform to others' expectations.

C. "You will feel better when you have your first ultrasound.": This statement minimizes the client’s current emotional state and assumes that reassurance will come from a future event, which may not address the underlying anxiety.

D. "Let's focus on how you are feeling physically.": While physical symptoms are important, this response deflects from the client's expressed emotional concern. It can shut down conversation about her psychological well-being, which is the main issue presented.

A. "Your family disagrees with your decision?" B. "Did you tell your provider that your family doesn't agree with your decision?" C. "You are making the same decision I would make." D. "You should get your family to agree with your decision before signing the consent."

Correct Answer is A

Explanation

Rationale:

A. "Your family disagrees with your decision?": This open-ended response reflects therapeutic communication by encouraging the client to express her feelings without judgment. It invites further discussion and shows the nurse’s support for the client’s autonomy and emotional well-being.

B. "Did you tell your provider that your family doesn't agree with your decision?": This response shifts focus away from the client's emotional conflict and places it on the provider. It may dismiss the client’s current need for support and hinder further emotional exploration.

C. "You are making the same decision I would make.": Personalizing the conversation undermines client autonomy. The nurse’s role is to support the client’s decision-making process, not impose personal opinions or make assumptions about what is best.

D. "You should get your family to agree with your decision before signing the consent.": This response suggests the client must yield to family opinions, which contradicts the principle of informed consent. The decision is ultimately the client’s, and family agreement is not a legal or ethical requirement.

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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

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