A nurse is teaching a client who is to undergo placement of a nontunneled percutaneous central venous access device. Which of the following statements should the nurse include in the teaching?

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: Contacting a family member weekly does not directly address fall prevention for a senior living alone. While social support is valuable, it does not mitigate physical fall risks like environmental hazards. This response fails to provide practical safety measures, making it inadequate for the client’s concern.
Choice B reason: Suggesting a move to a skilled nursing facility is extreme and dismisses the client’s autonomy to remain at home. Many seniors can live safely with modifications like grab bars or assistive devices. This response does not address immediate fall prevention strategies, making it inappropriate and overly restrictive.
Choice C reason: Having an unlicensed assistive person stay daily is impractical and costly for fall prevention. It does not address environmental hazards, the primary cause of falls. Home modifications and assistive devices are more effective and sustainable, making this response less appropriate than environmental safety measures.
Choice D reason: Installing grab bars and removing loose rugs directly reduces fall risks by improving stability and eliminating tripping hazards. These evidence-based modifications are effective for seniors living alone, enhancing safety without compromising independence. This response addresses the client’s fear with practical, actionable solutions, making it correct.