A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client.
Which of the following actions should the nurse take first?

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed

Choice A rationale:

Allowing the client to have time alone in their room might provide some relief, but it does not address the caregiver's overall stress and the impact on their life. Moreover, constant isolation is not a healthy solution for the client, as social interaction is essential for their well-being.

Choice B rationale:

Discussing methods of communication with the client about resolving problem behaviors is a helpful approach. Effective communication strategies can reduce misunderstandings and challenging behaviors, easing the burden on the caregiver. This choice demonstrates a proactive approach to improving the caregiver's situation.

Choice C rationale:

Assisting the caregiver in arranging for a daycare program for the client is an excellent solution. Adult daycare programs provide a safe and stimulating environment for individuals with Alzheimer's disease, allowing caregivers to have some respite while ensuring the well-being of their loved ones. This choice addresses both the client's needs and the caregiver's stress, making it the most appropriate option.

Choice D rationale:

Suggesting that the caregiver seek a prescription for an antipsychotic medication for the client is not the best course of action without a thorough evaluation by a healthcare provider. Antipsychotic medications have side effects and are typically prescribed based on the client's specific symptoms and needs. Additionally, prescribing medications is beyond the nurse's scope of practice and should be determined by a healthcare provider after a comprehensive assessment.