The client has a mediastinal chest tube.
Which symptoms require the nurse's immediate intervention?
Tracheal deviation.
Production of pink sputum.
Pain at the insertion site.
Sudden onset of shortness of breath.
Drainage greater than 100 ml/hr.
Correct Answer : A,D,E
Choice A rationale
Tracheal deviation is a classic and late sign of a tension pneumothorax, which is a life-threatening emergency. In a mediastinal context, shift of the trachea indicates significant pressure buildup in the thoracic cavity that can compress the heart and great vessels, leading to obstructive shock. This requires immediate needle decompression or chest tube adjustment. Normal tracheal position is midline, and any shift suggests a rapid compromise of respiratory and circulatory function necessitating urgent medical intervention.
Choice B rationale
Production of pink, frothy sputum often suggests pulmonary edema or minor airway irritation, but it is not the most acute finding specifically related to a mediastinal chest tube. While it requires assessment of oxygenation and heart failure markers, it does not represent the same immediate mechanical failure as a tension pneumothorax or massive hemorrhage. The nurse should monitor the patient's lung sounds and oxygen saturation, but other choices represent more direct and catastrophic complications.
Choice C rationale
Pain at the insertion site is an expected finding following the placement of a chest tube due to the stimulation of intercostal nerves and parietal pleura. While the nurse should provide adequate analgesia to facilitate deep breathing and prevent atelectasis, it is not an emergency requiring immediate intervention. Assessing the nature of the pain is important to rule out new complications, but it does not take priority over signs of hemodynamic or respiratory collapse in this scenario.
Choice D rationale
Sudden onset of shortness of breath is a hallmark sign of a recurring pneumothorax, tube occlusion, or pulmonary embolism. Rapid respiratory distress indicates that gas exchange is severely compromised, and the nurse must immediately assess breath sounds and the integrity of the chest drainage system. Rapid intervention is required to ensure the lung remains expanded and the patient is ventilated. This symptom reflects an acute change in clinical status that can lead to respiratory failure if ignored.
Choice E rationale
Drainage greater than 100 ml/hr from a mediastinal chest tube is a significant finding that may indicate active postoperative bleeding. While some drainage is expected, a rate exceeding this threshold requires immediate notification of the surgeon as the patient may require a return to the operating room for hemostasis. Excessive blood loss can lead to hypovolemic shock. Monitoring the trend of drainage is a standard nursing responsibility, and this specific volume is a widely recognized trigger for intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Pulmonary embolism causes an increase in pulmonary vascular resistance, which in turn increases the workload of the right ventricle. This back pressure is reflected in an elevated central venous pressure. The normal range for central venous pressure is 2 to 8 mm Hg. A reading of 12 mm Hg indicates that the right heart is struggling to pump blood forward through the lungs, causing volume to back up into the systemic venous circulation and the right atrium.
Choice B rationale
Mechanical ventilation, especially with the use of positive end-expiratory pressure, increases intrathoracic pressure. This increased pressure is transmitted to the heart and great vessels, which can artificially elevate the central venous pressure reading. Because the central venous pressure is measured relative to atmospheric pressure, the positive pressure within the chest pushes against the right atrium, resulting in a higher measured value even if the patient's actual fluid volume status has not significantly changed.
Choice C rationale
Hypovolemia, or a decrease in circulating blood volume, would typically cause a decrease in central venous pressure, not an elevation. When there is insufficient fluid in the vascular system, the pressure in the right atrium drops, often falling below the normal range of 2 to 8 mm Hg. Therefore, a reading of 12 mm Hg is inconsistent with a diagnosis of dehydration, hemorrhage, or other causes of low volume, as these would produce a much lower reading.
Choice D rationale
Diuretic therapy is intended to reduce fluid volume in the body by increasing urine output. Successful diuresis would lead to a reduction in the central venous pressure as the total intravascular volume decreases. If a patient has a central venous pressure of 12 mm Hg, it suggests they may be in a state of fluid overload or that the diuretics have not yet lowered the pressure to the normal range of 2 to 8 mm Hg.
Choice E rationale
Heart failure, specifically right-sided heart failure, leads to an inability of the ventricle to effectively eject blood. This results in an accumulation of blood in the right atrium and the systemic venous system, directly causing an elevation in central venous pressure. A reading of 12 mm Hg is a common finding in patients with congestive heart failure where the heart's pumping efficiency is compromised, leading to systemic venous congestion and potentially peripheral edema. .
Correct Answer is ["B","D"]
Explanation
Choice A rationale
This laboratory result represents metabolic acidosis, which is common in shock due to lactic acid accumulation from anaerobic metabolism. A pH of 7.22 is well below the normal range of 7.35 to 7.45. The bicarbonate level of 15 mEq/L is also low compared to the normal 22 to 26 mEq/L. These values indicate that the patient is still experiencing tissue hypoxia and inadequate perfusion, meaning the circulating volume and oxygen delivery have not been sufficiently restored.
Choice B rationale
These arterial blood gas values are within the normal physiological ranges. A pH of 7.35 is at the lower limit of normal, a PaCO2 of 40 mm Hg is exactly mid-range (normal 35 to 45 mm Hg), and a bicarbonate level of 22 mEq/L is at the lower limit of normal (normal 22 to 26 mEq/L). Achieving these values suggests that tissue perfusion is adequate to prevent the buildup of metabolic acids and that the respiratory system is effectively managing gas exchange.
Choice C rationale
The SaO2 measures the percentage of hemoglobin saturated with oxygen. A normal SaO2 value should be between 95 percent and 100 percent. A value of 76 percent is critically low and indicates severe hypoxemia. This could be due to continued blood loss, pulmonary complications from the trauma, or inadequate volume to transport oxygen. This measurement clearly demonstrates that the patient has not been stabilized and that the replacement of circulating volume and oxygenation is currently insufficient.
Choice D rationale
Normalization of vital signs and oxygen tension is a primary indicator of successful volume resuscitation. A blood pressure of 120/80 mm Hg and a pulse of 80 beats/minute are within standard normal limits, suggesting that the vascular space is adequately filled to maintain cardiac output. A PaO2 of 95 mm Hg is also within the normal range of 80 to 100 mm Hg, confirming that there is sufficient pressure to drive oxygen into the tissues following the transfusion.
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