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 B

Explanation

Rationale:
A. Decreased serum uric acid: In preeclampsia, serum uric acid levels are elevated, not decreased, due to reduced renal clearance and tissue ischemia. Increased uric acid is often one of the earliest laboratory indicators of preeclampsia.

B. Increased protein in urine: Proteinuria is a key diagnostic feature of preeclampsia resulting from glomerular endothelial damage that increases permeability to proteins. The presence of protein in the urine reflects kidney involvement and helps distinguish preeclampsia from gestational hypertension.

C. Increased platelet count: Preeclampsia is typically associated with thrombocytopenia (low platelet count) due to platelet aggregation and consumption within damaged blood vessels. An increased platelet count would not be expected in this condition.

D. Decreased BUN: In preeclampsia, renal perfusion is reduced, leading to elevated BUN and creatinine levels. A decrease in BUN would indicate improved kidney function, which is inconsistent with the pathophysiology of preeclampsia.

A. "Report bleeding that saturates the client's dressing." B. "Ensure the client's urinary output is no less than 20 mL per hour." C. "Expect the client to have a palpable distended bladder following surgery." D. "Maintain the client in a supine position for 24 hours following surgery."

Correct Answer is A

Explanation

Rationale:
A. "Report bleeding that saturates the client's dressing.": Excessive or saturating bleeding from a postoperative abdominal incision may indicate hemorrhage or disruption of the surgical site and requires immediate provider notification.

B. "Ensure the client's urinary output is no less than 20 mL per hour.": The expected minimum urinary output for an adult after surgery is at least 30 mL per hour, which reflects adequate renal perfusion and fluid balance. A urine output of 20 mL per hour is too low.

C. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected postoperatively and may signal urinary retention, a common complication due to anesthesia or opioids.

D. "Maintain the client in a supine position for 24 hours following surgery.": Keeping the client supine for 24 hours increases the risk of respiratory complications, including atelectasis and pneumonia. The nurse should encourage early ambulation and semi-Fowler’s positioning.

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