The nurse is performing an initial assessment of a patient with a chest tube placed in the eighth intercostal space.Which of the following findings would the nurse need to assess further? (Select all that apply. )
A)Respiratory rate of 18 breaths per minute
B)Continuous bubbling in the water-seal chamber
C)The presence of subcutaneous emphysema
D)Complaints of pain at the insertion site
E)Serous drainage on the chest tube dressing the size of a bean

Question

Quizplus · Accepted Answer

Continuous bubbling in the water-seal chamber could indicate a leak in the system and should be assessed further.The presence of subcutaneous emphysema must be assessed further because it can be caused by a poor seal at the chest tube insertion site.Complaints of pain at the insertion site can be expected but should be fully assessed before analgesics are administered.A respiratory rate of 18 breaths per minute falls within the normal range and does not,by itself,indicate a need for further assessment.A small amount of drainage on the chest tube dressing can be expected and serous drainage would be normal;however,it should be monitored for any change in appearance.

The Nurse Is Performing an Initial Assessment of a Patient