A nurse assesses a client who has a mediastinal chest tube.Which symptoms require the nurse's immediate intervention? (Select all that apply.)

Question

Quizplus · Accepted Answer

Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax.Sudden shortness of breath could indicate dislodgment of the tube,occlusion of the tube,or pneumothorax.Drainage greater than 70 mL/hr could indicate hemorrhage.Disconnection at the Y site could result in air entering the tubing.Production of pink sputum,oxygen saturation less than 95%,and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A Nurse Assesses a Client Who Has a Mediastinal Chest