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. Smoked salmon: Smoked and aged foods are high in tyramine, which can interact dangerously with phenelzine, a monoamine oxidase inhibitor (MAOI). This interaction can trigger a hypertensive crisis, making smoked salmon a food to avoid during therapy.

B. Cottage cheese: Cottage cheese contains low levels of tyramine compared to aged cheeses and is generally considered safe for clients taking MAOIs like phenelzine. It does not pose a significant risk for hypertensive crisis.

C. Grapefruit: Grapefruit can interact with many medications by affecting liver enzymes, but it does not have a known interaction with phenelzine. The concern with phenelzine is primarily with tyramine-rich foods, not citrus fruits.

D. Spinach: Spinach is not high in tyramine and does not interact with MAOIs. It is a leafy green that is safe and healthy for clients to consume while on phenelzine.

A. The client is drinking 2.5 L of water per day. B. The client started working in a parking garage 3 months ago. C. The client last visited the dentist 4 months ago. D. The client is doing 30 min of moderate exercise daily.

Correct Answer is B

Explanation

Rationale:

A. The client is drinking 2.5 L of water per day: Adequate hydration is important during pregnancy to support blood volume, amniotic fluid levels, and kidney function. A fluid intake of 2.5 liters per day is appropriate and does not raise concerns.

B. The client started working in a parking garage 3 months ago: Parking garages may expose individuals to carbon monoxide and other vehicle exhaust fumes, which can pose risks to fetal development. Prolonged exposure to poor air quality warrants further evaluation for potential harm.

C. The client last visited the dentist 4 months ago: Regular dental care is encouraged during pregnancy due to increased risk of gingivitis and periodontal disease. Visiting the dentist 4 months ago is within a normal range and does not signal unsafe behavior.

D. The client is doing 30 min of moderate exercise daily: Moderate exercise is recommended during pregnancy unless contraindicated. It improves circulation, mood, and energy, and supports healthy weight gain and fetal outcomes.

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