A nurse is teaching a class at a local senior center regarding safety in the home. A client states, “I am afraid of falling because I live alone and have no one to help me.” Which of the following statements should the nurse make?

Choice A reason: Marking drainage output every 48 hours is too infrequent to accurately assess drainage in a closed wound drainage system. Frequent monitoring (e.g., every shift) is needed to track output, detect complications like excessive bleeding, and ensure system functionality, making this intervention inadequate for assessment.
Choice B reason: Stripping the chest tube vigorously is not recommended, as it can increase intrathoracic pressure, risking tissue damage or bleeding. It does not assess drainage amount but manipulates the tube, potentially causing harm. Assessment requires observing output in the collection chamber, making this action incorrect.
Choice C reason: Maintaining the collection chamber below the client’s chest ensures proper drainage by gravity in a closed wound drainage system, like a chest tube. This position prevents backflow and allows accurate measurement of drainage output in the chamber, essential for assessing fluid loss and detecting complications like hemothorax.
Choice D reason: Adding water to the water seal chamber maintains system function but does not directly assess drainage amount. The water seal prevents air re-entry, not measures output. Assessment involves observing and recording drainage in the collection chamber, making this action irrelevant to the question’s focus.

Choice A reason: Percussion precedes palpation to assess abdominal resonance and organ size without altering bowel motility. Performing it last risks inaccurate findings, as palpation may stimulate peristalsis, changing resonance patterns. This sequence ensures reliable detection of abnormalities like organomegaly or fluid accumulation in the abdomen.
Choice B reason: Auscultation is done before palpation to capture natural bowel sounds. Manipulation during palpation can alter peristalsis, affecting auscultatory findings. Early auscultation ensures accurate detection of hypoactive or hyperactive bowel sounds, critical for diagnosing conditions like ileus or obstruction in abdominal assessments.
Choice C reason: Palpation is the final step, following inspection, auscultation, and percussion, to assess for tenderness or masses. This sequence prevents manipulation from altering earlier findings, ensuring accurate identification of abdominal abnormalities like peritonitis or organ enlargement, critical for a comprehensive physical examination.
Choice D reason: Inspection is the first step, providing a visual baseline of abdominal appearance, such as distension or scars. Performing it last misses initial cues guiding subsequent steps. Early inspection ensures no manipulation affects visual assessment, vital for identifying external signs of underlying abdominal pathology.