A nurse is caring for a 75.year.old male client who is experiencing difficulty breathing and shortness of breath.

Exhibits

The nurse is caring for the client following a thoracentesis. Select the 3 findings that require immediate follow.up.

A. Eyelets are not visible. The eyelets of the chest tube should not be visible if the tube is correctly positioned inside the pleural space. Visible eyelets indicate tube dislodgement, which is a concern, but the provider does not need to be notified if the chest tube is secure and functioning properly.
B. Bubbling of the water in the water seal chamber with exhalation. This is an expected finding in a client with a pneumothorax, as air escapes from the pleural space. Intermittent bubbling with exhalation, coughing, or sneezing indicates that the pneumothorax is resolving. Continuous bubbling, however, could indicate an air leak and would require further assessment.
C. Crepitus in the area above and surrounding the insertion site. Crepitus, or subcutaneous emphysema, occurs when air leaks into the subcutaneous tissue. While it can be a sign of a small air leak, it is not always an emergency. The nurse should monitor for increasing crepitus and signs of worsening respiratory distress, but immediate provider notification is not always required.
D. Movement of the trachea toward the unaffected side. Tracheal deviation is a sign of tension pneumothorax, a lifethreatening emergency that requires immediate intervention. It occurs when air continues to accumulate in the pleural space without an exit, leading to increasing intrathoracic pressure. This shifts the mediastinum and trachea away from the affected lung, compressing the heart and great vessels, which can rapidly lead to cardiac arrest. The provider must be notified immediately to prevent further deterioration.

A. Differences in upper and lower lung sounds. While pericarditis may cause pleuritic chest pain and a pericardial friction rub, differences in lung sounds between upper and lower fields are more commonly associated with pulmonary conditions like pneumonia or pleural effusion rather than atrial fibrillation.
B. Differences between oral and axillary temperatures. Temperature discrepancies are not related to atrial fibrillation. Though pericarditis may be accompanied by fever due to inflammation, AF is primarily an electrical disturbance and does not directly impact body temperature regulation.
C. Different apical and radial pulses. A pulse deficit, where the apical pulse is higher than the radial pulse, is a hallmark sign of atrial fibrillation. This occurs because the irregular, rapid atrial contractions lead to some ventricular beats that are too weak to produce a palpable radial pulse, indicating ineffective cardiac output.
D. Different blood pressures in the upper limbs. Significant differences in blood pressure between the arms are more indicative of vascular conditions such as aortic dissection or subclavian artery stenosis rather than atrial fibrillation, which primarily affects heart rhythm rather than arterial perfusion.