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.

Add water to the water seal chamber as it evaporates.

Mark the drainage output on the collection chamber.

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

Strip the chest tube vigorously to dislodge blood clots.

Answer and Explanation

Correct Answer : B,C

Rationale:

A. Clamp the chest tube every 2 hr to assess the amount of drainage: Clamping a chest tube is not routine and can lead to tension pneumothorax by preventing air or fluid from escaping the pleural space. It should only be done briefly and under specific provider direction.

B. Add water to the water seal chamber as it evaporates: Water in the water seal chamber may evaporate over time and should be maintained at the prescribed level to preserve the one-way seal. This ensures proper functioning of the chest drainage system.

C. Mark the drainage output on the collection chamber: Marking the drainage level at regular intervals allows for accurate monitoring of output trends, which can help detect complications like hemorrhage or increased fluid accumulation.

D. Maintain the collection chamber above the level of the client's waist: The collection chamber should be kept below the level of the chest to promote gravity drainage. Elevating it above the waist can allow fluid or air to flow back into the pleural space.

E. Strip the chest tube vigorously to dislodge blood clots: Stripping is not recommended as it creates high negative pressure that may damage lung tissue. If clots are suspected, milking the tube gently or other interventions should be discussed with the provider.

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Correct Answer is D

Explanation

Rationale:

A. Tachypnea: An increased respiratory rate is not commonly associated with epidural anesthesia and is not a typical adverse effect. It may result from anxiety or pain but does not directly indicate a problem with the epidural.

B. Hyperreflexia: Epidurals often reduce sensation and reflexes, not heighten them. Hyperreflexia is not expected and would not be a direct adverse effect of epidural administration during labor.

C. Hypothermia: While mild temperature changes may occur, hypothermia is not a common or significant adverse effect of epidural anesthesia. It is not typically monitored as a key complication.

D. Hypotension: Epidural anesthesia can cause vasodilation by blocking sympathetic nerve fibers, leading to a drop in maternal blood pressure. This is a well-known and common adverse effect requiring close monitoring and potential intervention.

A. Make an audio recording of the adolescent's responses B. Promise not to disclose information shared during the interview C. Obtain a history from both the adolescent and their caregiver. D. Use leading questions during the interview.

Correct Answer is C

Explanation

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor and just received an epidural. Which of the following findings should the nurse document as an adverse effect?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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