The clinic nurse administers a tuberculin skin test to a client. The nurse tells the client to return to the clinic for the results in?

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. Obtain the patient's vital signs:While monitoring vital signs is important, especially for detecting hypovolemia or underlying causes like hypertension, it is not the immediate priority. The nurse must first attempt to control the bleeding to prevent aspiration and continued blood loss.

B. Apply a cold compress to the patient's facial area:Cold compresses can help constrict blood vessels and reduce bleeding, but they are supportive measures. They should be done afterprimary pressure techniques have been initiated, not as the first-line intervention.

C. Firmly pack the nostril with saline soaked gauze:Nasal packing is typically a secondary measure used when direct pressure fails to stop the bleeding. It is more invasive and usually performed by trained personnel if conservative measures are ineffective.

D. Instruct the client to sit forward and pinch the nose below the nasal bone:Sitting forward prevents blood from flowing into the throat and airway, while pinching the soft part of the nose applies direct pressure to the bleeding vessels, which often successfully stops epistaxis.