The nurse is caring for a client diagnosed with pneumonia. Which medication will the nurse administer for treatment of client's problem of ineffective airway clearance?

A) Encouraging the client to cough and deep breathe every two hours:
Encouraging the client to cough and deep breathe is an important nursing intervention for clients with a chest tube. This helps promote lung expansion, prevent atelectasis, and improve respiratory function. It also helps to clear secretions that may accumulate in the lungs. Therefore, this practice is appropriate and beneficial for the client.

B) Stripping the chest tube to dislodge any blood clots:
Stripping the chest tube, which involves forcibly pulling or pinching the tubing to remove clots, is an unsafe and outdated practice. It can create a dangerous increase in intrathoracic pressure, which may lead to tension pneumothorax, as well as injury to the lung tissue. Instead, the nurse should focus on gently milking the chest tube if necessary (if prescribed by the healthcare provider) or ensure that any blood clots are properly managed by the physician. Stripping or clamping the tube without proper indications is contraindicated.

C) Assessing the client's respiratory status frequently:
Frequent assessment of the client's respiratory status is crucial when managing a patient with a chest tube. The nurse should monitor for signs of respiratory distress, changes in breath sounds, oxygen saturation, and any signs of complications such as pneumothorax or hemothorax. Regular respiratory assessment helps in early detection of issues and provides the data necessary to manage the client's care effectively.

D) Monitoring skin for subcutaneous emphysema:
Monitoring for subcutaneous emphysema is a vital part of nursing care for a client with a chest tube. Subcutaneous emphysema occurs when air escapes from the pleural space into the tissues under the skin, and can be a sign of a pneumothorax or a complication related to the chest tube. It is important to detect this early so appropriate intervention can be made to prevent further complications.

A. Call for the rapid response team and request a portable chest X-ray: While calling for assistance and obtaining a chest X-ray is important for further assessment, the immediate priority is to secure the wound to prevent air from entering the pleural space. This action will help stabilize the patient until the rapid response team arrives and the X-ray can be performed.

B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction and auscultating breath sounds may be necessary after the wound is secured, but these actions should not take priority over sealing the chest tube site. The focus at this moment is to prevent a tension pneumothorax by sealing the dislodged chest tube site. Auscultation of breath sounds is useful afterward to assess for respiratory complications, but it is not the first action to take.

C. Apply a sterile dressing and tape on three sides: The first action when a chest tube becomes accidentally dislodged is to seal the opening to prevent air from entering the pleural space, which could lead to a pneumothorax (collapsed lung). Applying a sterile dressing and taping it on three sides helps create a temporary one-way valve effect, allowing air to escape from the pleural space but preventing further air from being drawn in. This intervention is crucial to stabilize the patient while awaiting further evaluation and intervention.

D. Notify the healthcare provider immediately: Notifying the healthcare provider is essential, but it is not the first action. The most important initial step is to seal the chest tube site to prevent further complications. After the dressing is applied, the nurse can then notify the healthcare provider and continue to monitor the patient.