A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

Choice A rationale
Decreased temperature is not typically an immediate complication following a thoracentesis. It may indicate an infection, but this would develop over time rather than immediately after the procedure.
Choice B rationale
Serosanguineous drainage from the puncture site is expected after a thoracentesis and does not indicate a complication that requires immediate attention.
Choice C rationale
Shortness of breath is a serious complication that can indicate a pneumothorax or re- accumulation of fluid in the pleural space. This requires immediate attention and intervention by the healthcare provider.
Choice D rationale
Chest pain can be a sign of a complication such as a pneumothorax or infection. However, shortness of breath is a more immediate and severe symptom that requires urgent attention.

Choice A rationale
Bubbling of the water in the water seal chamber with exhalation. This statement is incorrect. Bubbling in the water seal chamber with exhalation can be normal and indicates that air is being expelled from the pleural space. It is not necessarily a cause for concern.
Choice B rationale
Eyelets are not visible. This statement is incorrect. The visibility of eyelets on the chest tube is not a standard indicator for notifying the provider. The focus should be on the function of the chest tube and the patient’s clinical status.
Choice C rationale
Movement of the trachea toward the unaffected side. This statement is correct. Tracheal deviation toward the unaffected side can indicate a tension pneumothorax, a life-threatening condition that requires immediate medical attention. It suggests that pressure is building up in the pleural space, compressing the lung and shifting the trachea.
Choice D rationale
Crepitus in the area above and surrounding the insertion site. This statement is incorrect. Crepitus, or subcutaneous emphysema, can occur when air leaks into the subcutaneous tissue around the chest tube insertion site. While it should be monitored, it is not necessarily an emergency requiring immediate notification of the provider.