The nurse is continuing to care for the client. 

Exhibits

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

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.

Rationale:

A. Prolonged QT interval: This is not a typical sign of morphine toxicity. QT prolongation is more commonly associated with certain antipsychotics, antiarrhythmics, or methadone, not opioids like morphine.

B. Fluid retention: Morphine does not typically cause fluid retention. While it may contribute to urinary retention, generalized fluid accumulation is not characteristic of opioid toxicity and may point to other causes like heart or renal failure.

C. Bradypnea: Respiratory depression, including bradypnea, is the hallmark sign of opioid toxicity. Morphine suppresses the brainstem’s respiratory centers, reducing respiratory rate and depth, which can become life-threatening without intervention.

D. Hyperactive deep tendon reflexes: Opioids tend to cause central nervous system depression, which would more likely lead to diminished reflexes. Hyperactive reflexes are not associated with morphine toxicity and may suggest a different neurological issue.