A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Clamp the chest tube every 2 hr to assess the amount of drainage.

Maintain the collection chamber above the level of the client's waist.

Strip the chest tube vigorously to dislodge blood clots.

Add water to the water seal chamber as it evaporates.

Mark the drainage output on the collection chamber.

Answer and Explanation

Correct Answer : D,E

Rationale:
A. Clamp the chest tube every 2 hr to assess the amount of drainage: Routine clamping of a chest tube is unsafe because it can cause a sudden buildup of pressure in the pleural space, leading to a tension pneumothorax.

B. Maintain the collection chamber above the level of the client's waist: The collection chamber should always be positioned below the level of the client’s chest to allow gravity drainage. Placing it above the waist would prevent proper drainage.

C. Strip the chest tube vigorously to dislodge blood clots: Vigorous stripping or milking of the chest tube can create excessive negative pressure, potentially damaging lung tissue. Current guidelines recommend gentle milking only if ordered and rarely if obstruction is suspected.

D. Add water to the water seal chamber as it evaporates: Maintaining the proper water level in the water seal chamber is essential to preserve the one-way valve function that prevents air from re-entering the pleural space. Evaporation can reduce the seal, so the nurse should routinely check and refill it.

E. Mark the drainage output on the collection chamber: Documenting drainage at regular intervals allows accurate monitoring of the client’s progress and early identification of complications such as increased bleeding or fluid accumulation. It supports timely communication with the healthcare provider.

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Correct Answer is D

Explanation

Rationale:
A. Diabetes screening: Screening is a form of primary or secondary prevention, aimed at early detection or prevention of disease, rather than tertiary prevention. It helps identify risk factors before complications develop.

B. Family planning: Family planning is a primary prevention strategy, focusing on preventing unintended pregnancies and promoting reproductive health. It does not address the management of existing conditions or complications.

C. Nutrition counseling: Nutrition counseling can serve as primary or secondary prevention depending on context, such as preventing chronic disease or managing early-stage conditions. It is not typically considered tertiary prevention.

D. Physical therapy: Physical therapy is a tertiary prevention intervention because it aims to improve function, reduce complications, and enhance quality of life for clients who already have a health condition. It helps manage existing disease and prevent further disability.

A. Obtain a 12-lead ECG for the client. B. Administer sublingual nitroglycerin to the client. C. Measure the client's vital signs. D. Have the client stop walking and sit down.

Correct Answer is D

Explanation

Rationale:
A. Obtain a 12-lead ECG for the client: An ECG is important to assess for myocardial ischemia or infarction, but it should be done after immediate measures are taken to reduce myocardial oxygen demand.

B. Administer sublingual nitroglycerin to the client: Nitroglycerin helps relieve chest pain by dilating coronary arteries, but it should be given only after the client is safely seated or resting to prevent hypotension or injury.

C. Measure the client's vital signs: Vital signs provide valuable baseline data, but addressing the client’s immediate safety and reducing cardiac workload takes priority.

D. Have the client stop walking and sit down: Stopping activity decreases oxygen demand on the heart and prevents worsening ischemia or collapse, making it the first and most critical action.

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A nurse is planning care for a client who has a chest tube. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

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