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The client has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? Select all that apply.

A.

Production of pink sputum

B.

Pain at the insertion site

C.

Tracheal deviation

D.

Drainage greater than 200 ml/hr

E.

Sudden onset of shortness of breath

Answer and Explanation

Correct Answer : C,D,E

Rationale:

A. Pink-tinged sputum may occur postoperatively due to minor irritation or small amounts of bleeding from the respiratory tract. While it should be monitored, it does not require immediate intervention unless it becomes massive or bright red.

B. Mild to moderate pain at the chest tube site is expected postoperatively and can be managed with analgesics. Pain alone, without other acute signs, does not indicate an emergency.

C. Tracheal deviation is a sign of tension pneumothorax, which is a life-threatening emergency. Immediate intervention is required to relieve pressure in the pleural space and restore ventilation. The nurse should notify the provider immediately and prepare for emergency measures, such as needle decompression or chest tube adjustment.

D. Excessive drainage from a mediastinal chest tube may indicate postoperative hemorrhage, which can rapidly lead to hypovolemic shock. Immediate assessment and provider notification are necessary to prevent severe complications and initiate interventions.

E. Acute shortness of breath in a patient with a mediastinal chest tube can indicate pneumothorax, tube blockage, or cardiac/respiratory compromise. This is an urgent situation requiring immediate assessment, oxygen support, and provider notification.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. PEEP helps keep alveoli open to improve oxygenation, but it does not increase the respiratory rate or prevent hypoventilation caused by decreased spontaneous breathing.

B. Pressure support assists spontaneous breaths by decreasing the work of breathing, but if the patient’s spontaneous rate has dropped to 4 breaths/min due to morphine, pressure support alone is insufficient to ensure adequate ventilation.

C. Assist/control ventilation delivers a set rate of mandatory breaths. Setting it at 4 breaths/min would be inadequate because the patient is hypoventilating and may require a higher mandatory rate to maintain adequate gas exchange.

D. SIMV delivers a set number of mandatory breaths, allowing spontaneous breaths in between. Since morphine has depressed the patient’s spontaneous rate from 12 to 4 breaths/min, increasing the mandatory SIMV rate ensures the patient receives adequate total ventilation, preventing hypoventilation and hypercapnia.

Correct Answer is B

Explanation

A. This is incorrect

B. Step 1: Convert mg to mcg
1 mg = 1000 mcg
0.1 mg = 0.1 × 1000 mcg
0.1 mg = 100 mcg

Step 2: Compare ordered dose with available dose
Ordered dose = 100 mcg
Available dose per tablet = 100 mcg

Step 3: Calculate number of tablets
Number of tablets = Desired dose ÷ Dose available
Number of tablets = 100 ÷ 100
Number of tablets = 1

Step 4: Match to the options
1 tablet

C. This is incorrect

D. This is incorrect

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