A client is prescribed warfarin for the prevention of venous thromboembolism (VTE) following a right knee replacement. What should the nurse have available for a warfarin overdose?

A. Pain at the insertion site:Mild to moderate pain is expected after chest tube placement and should be monitored, but it does not usually require immediate intervention unless it worsens or becomes severe. It is typically managed with routine analgesics.

B. Tracheal deviation:Tracheal deviation is a late and critical sign of tension pneumothorax, which requires immediate emergency intervention. It indicates severe pressure in the pleural space that can compress major vessels and impair cardiac output.

C. Drainage of 75 mL/hr:While slightly elevated, this drainage rate may be acceptable depending on the clinical context (e.g., post-thoracic surgery). The nurse should continue monitoring, but this does not require immediate action unless drainage exceeds 100–150 mL/hr.

D. Productive sputum:Productive sputum is not unusual in patients with underlying pulmonary conditions. Unless it is accompanied by signs of infection or changes in sputum color, amount, or consistency, it does not warrant immediate action.

E. Sudden onset of shortness of breath:A sudden change in respiratory status may indicate a complication such as tube dislodgement, blockage, or recurrent pneumothorax. This requires prompt evaluation and intervention to ensure adequate oxygenation and ventilation.

A. Perform suction with sterile supplies:Sterile technique is essential when suctioning a tracheostomy to prevent introducing pathogens into the lower airway. Sterile supplies and gloves help reduce the risk of infection in this direct airway access point.

B. Auscultate lungs for retained secretions:Before suctioning, the nurse should assess for signs that suctioning is needed, such as abnormal breath sounds (e.g., crackles, rhonchi) that indicate secretion buildup in the airways.

C. Don clean gloves and lift out catheter and connect to suction:Clean gloves are insufficient for the suctioning procedure. This is an invasive technique involving direct access to the lower airway, requiring sterile gloves and equipment to prevent infection.

D. Wash hands and open sterile suction kit:Hand hygiene is a fundamental part of infection control. Opening the sterile suction kit properly maintains the sterility of equipment needed for the procedure.

E. Inform the patient about the procedure:Providing a brief explanation prepares the patient, reduces anxiety, and promotes cooperation. Even if the patient is nonverbal, communication is part of professional and ethical nursing care.