Question

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

a. Production of pink sputum
b. Tracheal deviation
c. Oxygen saturation greater than 95%
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Pain at insertion site
g. Disconnection at Y site

Answer 1

A client with a mediastinal chest tube may require the nurse's immediate intervention for symptoms such as tracheal deviation, sudden onset of shortness of breath, and drainage greater than 70 mL/hr.

Step-by-step explanation:

For a client with a mediastinal chest tube, there are several symptoms that require the nurse's immediate intervention. These include:

1. Tracheal deviation: This occurs when the trachea is displaced away from the midline, which can indicate tension pneumothorax or a large effusion.
2. Sudden onset of shortness of breath: This could be a sign of a pneumothorax or worsening respiratory status.
3. Drainage greater than 70 mL/hr: Excessive drainage can indicate active bleeding or a significant leakage from the chest.

These symptoms require immediate nursing intervention to prevent further complications and ensure the client's safety.