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Loop the tubing of the chest tube on the client's bed: Looping the tubing can create kinks and obstruct drainage, increasing the risk of complications like tension pneumothorax.

Strip the client's chest tube every 2 hrs: Stripping the chest tube increases negative pressure in the system, which can damage lung tissue. Instead, gentle milking of the tube is acceptable if needed and directed by protocol.

Place the chest tube drainage system above the level of the client's heart. The drainage system should always remain below the level of the chest to facilitate gravity drainage and prevent fluid from flowing back into the pleural cavity.

Deflate the balloon halfway and then pull out the catheter: The balloon must be fully deflated to prevent trauma to the urethra during removal.

Have the client bear down during removal: Bearing down is unnecessary during catheter removal. It is used during voiding or procedures like rectal exams.

Cleanse the perineal area with an antiseptic: Cleansing with an antiseptic is important before insertion, but after removal, hygiene with soap and water suffices.

"We will rotate the probe of the pulse oximeter every 24 hours.": Rotating the probe prevents skin breakdown from prolonged pressure.

"The probe of the pulse oximeter can be applied to a finger or a toe.": This is an appropriate placement for infants to ensure accurate readings.

"The pulse oximeter might not be accurate during times of excessive movement.": Movement artifacts can lead to inaccurate readings.

Reflex incontinence: Reflex incontinence occurs due to involuntary bladder contractions, not retention, and doesn't necessarily indicate the need for catheterization.

Nocturnal enuresis: Nighttime incontinence is a symptom but does not indicate immediate need for catheterization unless associated with retention or discomfort.

Urge incontinence: This indicates overactivity of the bladder rather than retention; catheterization isn't typically necessary unless retention follows the urge.

Immediately before meals: Although the gastrocolic reflex is stimulated after eating, taking the client immediately before meals does not align with the natural defecation reflex.

Every 2 hr while the patient is awake: This does not consider the client’s natural bowel patterns and may lead to frustration or noncompliance.

After the client feels abdominal cramping: Cramping could indicate discomfort from gas or constipation, not necessarily the optimal time for defecation.

Stress incontinence: Stress incontinence involves leakage caused by increased abdominal pressure (e.g., sneezing or laughing) and is unrelated to nerve damage.

Urge incontinence: Urge incontinence is characterized by a sudden, intense need to urinate, which is not typically seen with spinal cord injury-related nerve damage.

Overflow incontinence: Overflow incontinence results from incomplete bladder emptying, often due to obstruction or weakened bladder muscles, not reflexes from nerve damage.

Tachycardia: Tachycardia is more commonly associated with hypoxia rather than a direct adverse effect of oxygen therapy.

Excessive pulmonary secretions: Oxygen therapy does not directly cause excessive secretions; this is more related to the underlying condition, such as pneumonia.

Poor skin turgor: Poor skin turgor is associated with dehydration, not oxygen therapy.

Decrease in systolic blood pressure: Incorrect. Aging often results in increased systolic blood pressure due to arterial stiffening, not dehydration risk.

Increase in percentage of body water: Incorrect. Aging is associated with a decrease, not an increase, in body water, contributing to dehydration risk.

Increase in saliva production: Incorrect. Aging leads to reduced saliva production, not an increase, but this is not directly related to dehydration.

Use one cotton swab to clean the client's urinary meatus: Multiple cotton swabs should be used to clean in a systematic manner to maintain asepsis.

Test the balloon on the indwelling urinary catheter before insertion: Pretesting the balloon is unnecessary and may compromise sterility or damage the balloon.

Apply an oil-based lubricant to the indwelling urinary catheter: Only water-based lubricants should be used to prevent catheter damage or client harm.