A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion.
Which of the following actions should the nurse include in the plan?

Choice A rationale:

Administering a laxative to a client with acute appendicitis is contraindicated. Laxatives can increase bowel motility, which may aggravate the inflamed appendix and lead to rupture. Rupture of the appendix can result in a life-threatening condition known as peritonitis.

Choice B rationale:

Keeping the client on NPO (nothing by mouth) status is the correct choice. NPO status is essential in the management of acute appendicitis. It helps to rest the bowel, prevents stimulation of the appendix, and decreases the risk of rupture. Oral intake, including food and fluids, is usually restricted until the client undergoes surgery to remove the inflamed appendix (appendectomy).

Choice C rationale:

Placing the client's head of bed flat is not the optimal position for a client with acute appendicitis. Elevating the head of the bed slightly (semi-Fowler's position) can help reduce discomfort and minimize pressure on the abdomen. This position is more comfortable for the client and can aid in pain management.

Choice D rationale:

Applying heat to the client's abdomen is not recommended in acute appendicitis. Heat application can increase blood flow to the area, potentially worsening inflammation and exacerbating pain. Cold packs or ice packs are sometimes used to provide comfort, but their application should be done cautiously to avoid skin damage. However, in many cases, healthcare providers prefer to avoid temperature applications to prevent masking symptoms and signs of worsening appendicitis.

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed