Which patient(s) would be able to take an alpha-adrenergic decongestant safely? (SELECT ALL THAT APPLY)

A. Add tap water as needed to the suction control chamber.

This is not the correct action. The suction control chamber of a water-seal chest tube drainage system is typically filled with sterile water to the prescribed level by the healthcare provider during the initial setup. Adding tap water to the suction control chamber can disrupt the balance of the system and affect the prescribed suction level. The nurse should not add tap water without specific instructions from the healthcare provider.

B. Maintain the drainage container below the level of the client's chest.

This is the correct action. In a water-seal chest tube drainage system, it's important to keep the drainage container below the level of the client's chest. This positioning allows gravity to assist in the drainage of air or fluid from the pleural space into the drainage container. It also helps prevent backflow of fluid or air into the chest cavity, ensuring the effectiveness of the drainage system.

C. Empty the collection container every shift.

While it may be necessary to empty the collection container if it becomes full, emptying it every shift is not a set rule. The frequency of emptying the collection container should be based on the volume of drainage and the facility's policy. The nurse should monitor the collection container regularly and empty it when it reaches the appropriate level, typically around half full or as indicated by facility protocol.

D. Clamp the chest tubes if it becomes disconnected.

Clamping the chest tubes if they become disconnected is not recommended. It can lead to tension pneumothorax, a life-threatening condition where air accumulates in the pleural space and compresses the lung. If a chest tube becomes disconnected, the nurse should immediately assess the situation, secure the chest tube connections, and notify the healthcare provider for further management.

A. Turn off the ventilator alarms before suctioning the client's airway.

This choice is incorrect because it goes against standard practice. Ventilator alarms are critical for monitoring the patient's respiratory status and detecting any issues with the ventilator or the patient's airway. Turning off alarms before suctioning can lead to missed alarms and potentially dangerous situations for the patient.

B. Provide mouth care every 10 to 12 hr with hydrogen peroxide.

This choice is incorrect because using hydrogen peroxide for mouth care is not recommended. Hydrogen peroxide can be irritating to the mucosa and may cause harm to the patient's oral tissues. Instead, gentle oral care with an appropriate solution, such as a mouthwash specifically designed for oral hygiene in ventilated patients, is preferred. Mouth care should also be provided more frequently than every 10 to 12 hours to maintain oral hygiene and prevent complications such as ventilator-associated pneumonia.

C. Place the head of the client's bed at 40° when supine.

This choice is correct. Proper positioning of the patient is crucial for optimizing ventilation and preventing complications such as aspiration and ventilator-associated pneumonia. Elevating the head of the bed to 40 degrees when the patient is in a supine position helps to minimize the risk of aspiration by promoting drainage of secretions away from the airway and improving lung expansion.

D. Reposition the client every 4 hr.

This choice is not directly related to care for clients receiving mechanical ventilation. While repositioning the patient every 4 hours is important for preventing pressure ulcers and maintaining skin integrity, it is not specific to mechanical ventilation care. However, it is still an important aspect of overall patient care, particularly for patients who are immobile or confined to bed for extended periods.