A nurse assesses a client who has a chest tube. For which ...

[vicotolentino]

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
 
  a. Production of pink sputum
  b. Tracheal deviation
  c. Sudden onset of shortness of breath
  d. Pain at insertion site
  e. Drainage of 75 mL/hr

Question 2

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.)
 
  a. What color is your sputum?
  b. Do you have any difficulty sleeping?
  c. How long does it take to perform your morning routine?
  d. Do you walk upstairs every day?
  e. Have you lost any weight lately?

[rnehls]

Answer to Question 1

ANS: B, C
Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.

Answer to Question 2

ANS: B, C, E
Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.