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The patient's oxygen saturation which is 100% on room air: A saturation of 100% indicates adequate oxygenation and is reassuring. There is no immediate concern, so it does not require urgent reporting.

The patient is complaining of mild pain at the chest tube insertion site: Mild pain is expected after chest tube placement and can typically be managed with analgesics. It does not represent an emergency and is monitored routinely.

A temperature of 99.9 F: A slightly elevated temperature is not uncommon post-procedure and does not indicate a critical complication. Fever monitoring should continue, but this finding does not necessitate immediate reporting.

To prevent atmospheric air from entering the pleural space: Preventing air entry is primarily the role of the water seal chamber, which allows one-way flow of air out of the pleural space while preventing backflow.

To collect drainage from the pleural space: Collecting fluid or blood is the function of the collection chamber, not the suction control chamber. The suction control chamber does not store drainage but regulates pressure.

To indicate the presence of an air leak: Air leaks are identified by observing bubbling in the water seal chamber, not the suction control chamber. Continuous or intermittent bubbling in the water seal indicates an air leak along the drainage system or from the pleural space.

Extracorporeal membrane oxygenation: ECMO is an invasive form of life support involving cannulation of large blood vessels to oxygenate blood externally. It is reserved for severe respiratory or cardiac failure and is not considered non-invasive ventilation.

Mechanical ventilator: Mechanical ventilation involves endotracheal intubation, making it an invasive method of providing respiratory support. It bypasses the upper airway and directly delivers air into the lungs.

Bi-PAP: Bi-level Positive Airway Pressure (Bi-PAP) delivers pressurized air through a mask without the need for an artificial airway. It is non-invasive and supports patients with conditions like COPD exacerbations or sleep apnea by improving ventilation and reducing the work of breathing.

Increased heart rate: Heart rate affects cardiac output but does not directly shift the oxyhemoglobin dissociation curve. It influences oxygen delivery to tissues but is not a cause of right- or leftward shifts in hemoglobin’s oxygen affinity.

Decreased 2,3-DPG: Lower levels of 2,3-DPG increase hemoglobin’s affinity for oxygen, causing a left shift on the dissociation curve. This makes oxygen unloading at the tissues more difficult rather than promoting a right shift.

Decreased temperature: Lower temperature enhances hemoglobin’s affinity for oxygen, resulting in a leftward shift of the curve. Oxygen is held more tightly by hemoglobin, which is opposite of a right shift.

Increase the settings on the Bi-PAP machine on your own and continue to monitor the patient: Adjusting Bi-PAP settings independently is not within the nurse’s scope of practice and could risk barotrauma or hemodynamic instability.

Recommend starting the patient on antibiotics to the healthcare provider: Oxygen saturation alone does not indicate infection. Initiating antibiotics without other clinical evidence or provider orders is inappropriate and could lead to unnecessary treatment.

Take no action at this time and continue to monitor the patient: While the patient is stable, leaving the provider uninformed delays potential interventions that may improve oxygenation. Active communication ensures timely and safe management of suboptimal oxygen saturation.

Oropharyngeal airway: Oropharyngeal airways can only be used in unconscious patients because they trigger a gag reflex in alert patients, which can cause vomiting or airway obstruction.

Endotracheal tube: Endotracheal intubation typically requires sedation or anesthesia in conscious patients because it involves passing a tube through the vocal cords into the trachea, which is highly uncomfortable and stimulates a strong gag reflex.

Chest tube: A chest tube is not an airway device; it is used to drain air, blood, or fluid from the pleural space. It does not assist with maintaining an open airway and is unrelated to airway management.

Normal fluctuation with breathing: Normal fluctuation, known as tidaling, involves the water level in the water seal chamber rising during inspiration and falling during expiration. Continuous bubbling, however, is not normal and indicates a different issue.

Fluid accumulation in the pleural space: Fluid in the pleural space would be indicated by increased drainage in the collection chamber, not by continuous bubbling in the water seal chamber. Bubbling is related to air movement, not fluid buildup.

Chest tube obstruction: An obstruction would cause absent or decreased drainage and loss of tidaling, not continuous bubbling. Bubbling requires airflow through the system, which would not occur if the tube were blocked.

Hyperoxemia: Excess oxygen in the blood usually does not cause anxiety, confusion, or tachypnea. In fact, patients with hyperoxemia are typically asymptomatic unless oxygen toxicity develops over a prolonged period, which is not consistent with these acute symptoms.

Hypercapnia: Elevated CO2 levels typically cause symptoms such as headache, flushed skin, drowsiness, and eventually lethargy. Although confusion can occur, hypercapnia usually leads to hypoventilation rather than tachypnea.

Alkalosis: Alkalosis, particularly respiratory alkalosis, can cause lightheadedness and paresthesia but rarely leads to confusion and significant anxiety unless it is severe. The described symptoms more strongly suggest low oxygen levels rather than an altered pH state.

Administer bronchodilators: Bronchodilators can help relieve airway constriction in COPD exacerbations, but they do not address the patient’s current severe hypoxemia and hypercapnia. Bronchodilator therapy is supportive rather than the priority in this scenario.

Start high-flow nasal cannula oxygen therapy: High-flow oxygen can improve oxygenation, but in the presence of hypercapnia, it may not adequately support ventilation and could delay necessary ventilatory assistance.

Prepare for immediate intubation: Intubation may become necessary if NIPPV fails or the patient deteriorates, but the patient is currently able to protect his airway and may respond to non-invasive ventilation. Immediate intubation is not the first-line intervention in this stable patient.

Increase NIPPV settings: While adjusting NIPPV settings may temporarily improve ventilation, persistent hypoxemia and hypercapnia despite optimal non-invasive support indicate that NIPPV is no longer sufficient to maintain adequate gas exchange.

Switch to high-flow nasal cannula: High-flow oxygen can improve oxygenation but does not provide ventilatory support for hypercapnia. Since the patient already has elevated PaCO2 and worsening acidosis, high-flow nasal cannula is unlikely to meet his ventilatory needs.

Administer high-dose corticosteroids: Corticosteroids may be indicated for inflammation management in COVID-19 or COPD exacerbations, but they do not address acute ventilatory failure. Immediate airway support takes priority over pharmacologic therapy in this situation.