The nurse is caring for a client who presents to the Emergen…

The nurse is caring for a client who presents to the Emergency Department following a motor vehicle accident. The nurse documents the initial assessment findings below.  Vital Signs  Assessment Findings  99.8 F  110 beats per minute  24 breaths per minute, labored  90/72 mmHg  87% on 2L/min per nasal cannula  Pain rated 8/10  Bruising noted over client’s left chest  Auscultation of left chest reveals absent breath sounds  Jugular venous distention noted  Client trachea appears deviated to the right  After contacting the healthcare provider, the client is diagnosed with spontaneous pneumothorax. A needle decompression takes place, along with chest tube insertion into the left 2nd intercostal space which is connected to a closed drainage system. Based on the diagnosis, identify whether the interventions listed below are indicated or contraindicated for the client.  Clamp the client’s chest tube prior to transferring the client to the radiology department Monitor for tidaling that is consistent with client’s respirations Assess the chest tube and drainage system once every shift   Keep the drainage system lower than the level of the chest Educate client that they can remove the drainage system when ambulating to the bathroom