The nurse is caring for a client with a chest tube. Which nursing assessment would alert the nurse to a possible complication?

Skin around tube is pink.

The tissues give a crackling sensation when palpated.

Absence of bloody drainage in the anterior/upper tube

Bloody drainage is observed in the collection chamber.

Answer and Explanation

The Correct Answer is B

A. Skin around tube is pink: Pink, healthy-appearing skin suggests normal circulation and lack of infection or irritation. This is an expected finding and does not indicate a complication related to chest tube placement or function.
B. The tissues give a crackling sensation when palpated: This is indicative of subcutaneous emphysema, a complication where air leaks into the subcutaneous tissue. It feels like bubble wrap under the skin and may signal a chest tube malfunction or air leak in the system.
C. Absence of bloody drainage in the anterior/upper tube: The anterior/upper chest tube typically drains air, not fluid or blood. The absence of bloody drainage here is expected and not cause for concern unless paired with respiratory distress.
D. Bloody drainage is observed in the collection chamber: Bloody drainage may be expected postoperatively, especially after thoracic surgery. It should be monitored for amount and rate, but its presence alone is not necessarily a complication.

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Correct Answer is C

Explanation

A. Dyspnea when ambulating from the bathroom: Mild exertional dyspnea is common in cardiac clients and may not require immediate provider notification unless it worsens or becomes unrelieved with rest.
B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration: An irregular pulse may warrant holding the medication and further assessment, but it is not always an emergency unless associated with hemodynamic instability or bradycardia.
C. Pulsus paradoxus on vital sign assessment: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, may indicate cardiac tamponade or severe pericardial effusion. It is a critical finding that requires immediate medical attention.
D. Cyanosis with a pulse oximetry level of 92%: While cyanosis is concerning, a SpO₂ of 92% may be acceptable for some cardiac or pulmonary patients. Further monitoring is needed, but it may not require urgent notification unless oxygen levels drop further.

A. Fever, sore throat, and chills B. Nausea and vomiting C. Intolerance to heat and rash D. Diarrhea, diaphoresis, and fever

Correct Answer is A

Explanation

A. Fever, sore throat, and chills: These are classic signs of infection and are especially concerning in leukopenia, where the body’s ability to fight infections is compromised due to a low white blood cell count. Prompt recognition is critical for early intervention.
B. Nausea and vomiting: While these may be side effects of many medications, they are not specific indicators of leukopenia. They reflect gastrointestinal irritation rather than immunosuppression.
C. Intolerance to heat and rash: These symptoms are more consistent with thyroid dysfunction or allergic reactions, not leukopenia. They do not suggest a compromised immune response.
D. Diarrhea, diaphoresis, and fever: Though fever can be a sign of leukopenia-related infection, diarrhea and diaphoresis are nonspecific symptoms and may relate to other systems or drug side effects. Fever, sore throat, and chills are more indicative of infection due to leukopenia.

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The nurse is caring for a client with a chest tube. Which nursing assessment would alert the nurse to a possible complication?

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