An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

A. Protein intake, especially animal protein (such as meat and dairy), can increase the excretion of calcium and other minerals into the urine, potentially leading to the formation of certain types of kidney stones (like calcium stones). Therefore, clients with a history of kidney stones are generally advised to moderate their intake of animal protein.
B. Some types of tea, particularly black tea, contain oxalates, which are substances that can contribute to the formation of calcium oxalate kidney stones in susceptible individuals. Therefore, clients with kidney

stones may be advised to limit their intake of tea, especially if they have a history of calcium oxalate stones.
C. High dietary sodium intake can increase calcium excretion in the urine, which may lead to the formation of calcium-containing kidney stones. Therefore, clients with kidney stones are often advised to reduce their sodium intake to help prevent stone formation.
D. Adequate fluid intake, primarily in the form of water, is crucial for preventing kidney stones. Increased water intake helps dilute urine and reduces the concentration of stone-forming substances, making it less likely for crystals to form and grow into stones. The goal is typically to produce at least 2 to 2.5 liters (about 8 to 10 cups) of urine per day.

A. Clamping the chest tubes is contraindicated because it can lead to tension pneumothorax, a life- threatening condition where air accumulates in the pleural space under pressure. If the chest tube becomes disconnected, the nurse should immediately place the end of the tube in sterile water to maintain the water seal and prevent air from entering the pleural space.
B. The drainage container must always be kept below the level of the client's chest. This position allows gravity to facilitate drainage from the pleural space into the collection chamber. If the container is positioned above the client's chest, drainage could potentially flow back into the pleural space, leading to complications.
C. It is essential to monitor and record the amount and characteristics of drainage regularly. Emptying the collection container at least once every shift ensures accurate measurement of drainage output and helps in assessing the client's response to treatment.
D. The water-seal chamber of the chest drainage system maintains the desired amount of suction (usually
-20 cm H2O) to facilitate lung re-expansion. This chamber should be filled with sterile water to the recommended level, usually marked on the device. Adding tap water can introduce contaminants and should be avoided.