A client is being treated for bacterial pharyngitis. Which of the following should a nurse recommend when promoting the client's nutrition during treatment?

• Assess for subcutaneous emphysema: Assessing for subcutaneous emphysema is crucial because it can indicate that air is escaping into the subcutaneous tissue, often resulting from a significant air leak. Early detection of subcutaneous emphysema allows for timely intervention, which is essential to manage the complication effectively and prevent further respiratory compromise.
• Check the drainage system and tubing: Checking the drainage system and tubing is important to ensure that the chest tube and drainage system are functioning correctly. This includes identifying any kinks, disconnections, or leaks in the tubing that could contribute to the air leak. Ensuring the integrity of the drainage system is vital for effective management of the client’s respiratory condition and for restoring proper lung expansion.
• Obtain blood cultures: This action is not indicated in this scenario unless there are signs of infection. The client’s symptoms do not suggest an infection requiring cultures at this time. Blood cultures would be more appropriate if there were signs of systemic infection, such as fever or elevated white blood cell count.
• Administer prescribed blood products: This action is also not appropriate unless there is evidence of significant bleeding or anemia. The client’s hemoglobin levels are within normal limits, so this intervention is not necessary.
• Observe surgical dressing: While important for monitoring the integrity of the surgical site, this action is not the priority when assessing for an air leak. Observing the dressing can help identify signs of drainage or infection but should follow the assessment for subcutaneous emphysema and the examination of the drainage system.
• Respiratory status: Monitoring the client's respiratory status is crucial for assessing lung function and detecting any changes in breathing patterns, oxygen saturation, or the presence of respiratory distress. Given the client's recent thoracotomy, careful observation can help identify complications early.
• Chest tube drainage: Assessing chest tube drainage is important to monitor the amount and type of fluid draining from the chest, as well as to identify any changes that may indicate bleeding or other complications. The 50 mL of sanguineous drainage noted since 0700 should be tracked to ensure it remains within acceptable limits and does not indicate excessive bleeding.
• Client's ability to perform lung expansion exercises: While important for overall respiratory health, monitoring the client’s ability to perform lung expansion exercises is not as critical in the context of an acute air leak. However, encouraging lung expansion exercises can help prevent complications such as atelectasis.
• Sputum: Monitoring sputum can provide information about respiratory status and potential infections. In this case, assessing sputum may be relevant but is secondary to monitoring respiratory status and chest tube drainage.
• Blood pressure: Blood pressure is important to monitor but is not the primary focus in the context of chest tube management and respiratory issues. Monitoring blood pressure can provide information about the client’s overall hemodynamic stability but is not directly related to assessing the air leak.
• Bleeding: While the client has some sanguineous drainage, the amount (50 mL) is not excessive, and hemoglobin levels are within normal limits. There are no signs of significant hemorrhage, making bleeding a less likely primary condition.
• Pulmonary edema: Pulmonary edema typically presents with symptoms such as dyspnea, cough with frothy sputum, and hypoxia. The client's symptoms and findings do not support a diagnosis of pulmonary edema, which is more commonly associated with heart failure.
• Pneumonia: While pneumonia can present with respiratory distress and abnormal lung sounds, the absence of fever and the clear sputum do not strongly indicate this condition in the current scenario. The findings are more consistent with an air leak.
• Air leak: The presence of tidaling in the water seal chamber along with continuous bubbling in the chest tube drainage system suggests an air leak. Continuous bubbling indicates that air is escaping into the pleural space, which can compromise lung expansion and lead to respiratory complications. This situation necessitates immediate attention to prevent further respiratory distress.

A. Client develops ecchymosis at the venipuncture site. Minor bruising at venipuncture sites is a common and expected side effect of heparin therapy due to its anticoagulant effect. While the nurse should monitor for increased bruising, isolated ecchymosis at an IV site does not necessarily indicate excessive anticoagulation or require immediate provider notification.
B. PTT 70 seconds (control 25-40). Heparin therapy is adjusted based on the activated partial thromboplastin time (aPTT). The therapeutic range is typically 1.5 to 2.5 times the control value, which in this case would be approximately 60-100 seconds. A PTT of 70 seconds is within the therapeutic range, so it does not require urgent intervention.
C. Client develops hematuria. Hematuria is a sign of potential excessive anticoagulation or internal bleeding, which can be a serious complication of heparin therapy. This finding suggests that the client's coagulation status may need immediate reassessment, and the heparin infusion may require adjustment or reversal with protamine sulfate if necessary. The healthcare provider should be notified promptly.
D. Order for Coumadin 2.5 mg to begin today. It is common practice to start warfarin (Coumadin) while a client is on heparin therapy because warfarin takes several days to reach therapeutic levels. Heparin is typically continued until the INR reaches a therapeutic range. Therefore, this order does not require provider notification.