The nurse plans care for a client with a brain tumor who developed a syndrome of inappropriate antidiuretic hormone.
Which interventions should the nurse include in the plan? Select all that apply.

Maintaining airway patency while managing intracranial pressure requires a balance between oxygenation and avoiding spikes in pressure. Knowledge of airway management and the physiological effects of hypoxia on cerebral edema is essential for prioritizing immediate life-saving interventions.

Choice A rationale

Elevating the head of the bed to 30 to 45 degrees promotes venous drainage and reduces intracranial pressure. While a standard nursing intervention for these patients, it does not clear an obstructed airway caused by pooled secretions.

Choice B rationale

Limiting stimulation helps prevent sudden increases in intracranial pressure caused by environmental stress. Although important for neurological stability, it is not the priority when the client's airway is compromised by secretions that prevent adequate ventilation.

Choice C rationale

Suctioning is necessary to clear the airway and maintain oxygenation. Hypoxia and hypercapnia are potent vasodilators that significantly increase intracranial pressure. Clearing the airway is the first priority, though it should be done quickly to minimize stimulation.

Choice D rationale

Sedatives may be used to reduce metabolic demand and blunt the intracranial pressure response to noxious stimuli like suctioning. However, administration takes time and does not physically remove the secretions causing the immediate airway obstruction..

The nurse must utilize knowledge of thoracic drainage mechanics and equipment troubleshooting. A three-chamber system requires consistent suction to maintain negative pleural pressure. Identifying the cause of suction failure involves systematic assessment of the external vacuum source and tube integrity.

Choice A rationale

Suction control chambers in wet systems require active external suction to function. Bubbling indicates vacuum application. Verifying the regulator is on ensures the system has the mechanical force necessary to maintain the ordered negative pressure for lung re-expansion.

Choice B rationale

Milking or stripping chest tubes creates high levels of negative pressure that can damage delicate lung tissue. This practice is generally contraindicated unless specifically ordered by a surgeon, as it increases the risk of pleural trauma and tension pneumothorax.

Choice C rationale

Absence of bubbling in the suction control chamber of a wet system is an abnormal finding. It signifies a lack of active suctioning. The nurse cannot ignore this, as effective pleural drainage depends on continuous atmospheric pressure regulation.

Choice D rationale

While water levels dictate suction intensity, adding water will not resolve a lack of bubbling if the suction source is off. Bubbling is caused by air passing through water via the suction regulator, not the volume itself.