A client with a mediastinal chest tube is being assessed by a nurse. Which symptoms require the nurse's immediate intervention? (SATA)

Correct Answer: B

Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent further complications. The other choices are incorrect because: A: Production of pink sputum may indicate blood-tinged sputum, which could be a sign of minor bleeding but does not require immediate intervention. C: Pain at insertion site is common after chest tube insertion and can be managed with pain medication, not necessarily requiring immediate intervention. D: Sudden onset of shortness of breath could indicate various issues, including pneumothorax, but tracheal deviation is a more specific and urgent sign that requires immediate attention.

Correct Answer: B

Rationale: Pulmonary function tests (PFTs) are diagnostic procedures that evaluate lung function, requiring precise coordination between the nurse and respiratory therapist to ensure accurate results. The correct answer is **B: "The client is ready to go down to radiology for this examination,"** because PFTs are typically performed in a specialized pulmonary function lab or respiratory therapy department, not radiology. This miscommunication could lead to delays or confusion, as radiology is not the correct location for PFTs. The nurse should verify the correct testing location with the respiratory therapist to ensure the client is directed appropriately. **Why the other options are incorrect:** **A: "I held the client's morning bronchodilator medication."** Holding bronchodilators before PFTs is often necessary because these medications can artificially improve lung function, skewing test results. However, this statement is not directly relevant to pre-test communication with the respiratory therapist. The therapist does not need this information to perform the test—instead, it is part of the nurse's responsibility to follow pre-test protocols. The respiratory therapist focuses on administering the test, not medication management. **C: "Physical therapy states the client can run on a treadmill."** While some PFTs (such as cardiopulmonary exercise testing) may involve treadmill use, standard spirometry or diffusion capacity tests do not. This statement is irrelevant unless the specific PFT requires exercise, which is uncommon in basic assessments. Including unnecessary details may confuse the therapist or imply an incorrect test type. The nurse should clarify the exact PFT being performed before relaying unrelated physical therapy clearance. **D: "I advised the client not to smoke for 6 hours prior to the test."** Smoking before PFTs can affect results by irritating airways and altering lung function. However, this is another pre-test nursing responsibility, not a critical communication point for the respiratory therapist. The therapist expects the client to arrive prepared; their role is to conduct the test, not verify smoking cessation. The nurse should document this instruction in the client's chart rather than report it to the therapist. In summary, effective communication before PFTs should focus on logistical coordination (e.g., correct testing location) rather than reiterating pre-test instructions that are the nurse's duty. Misplaced statements (A, D) or irrelevant details (C) distract from ensuring the procedure is performed efficiently. The priority is confirming the client is in the right place at the right time with the necessary preparations already completed.

Correct Answer: A

Rationale: The correct answer is A because smoking while on nicotine replacement therapy can lead to nicotine overdose, increasing the risk of a stroke due to excessive nicotine intake. This statement emphasizes the importance of avoiding smoking during treatment. Choice B is incorrect as it does not address the specific risk associated with smoking while on the medication. Choice C is incorrect as stopping the medication suddenly does not directly increase the risk for a heart attack. Choice D is irrelevant to nicotine replacement therapy and does not provide information related to the medication's use.

Correct Answer: B

Rationale: The correct answer is B: Notify Rapid Response Team. Continuous cyanosis despite oxygen therapy after benzocaine spray indicates possible methemoglobinemia, a life-threatening condition. Rapid Response Team can provide immediate intervention and transfer to a higher level of care. Administering albuterol (A) is not indicated for methemoglobinemia. Assessing peripheral pulses (C) may not address the underlying issue. Obtaining blood and sputum cultures (D) is not the priority in this acute situation.

Correct Answer: A

Rationale: The correct answer is A: Document findings. This is important because the harsh hollow sound over the trachea and larynx could indicate a potential emergency or serious condition like an airway obstruction or laryngeal edema. Documenting findings helps in providing clear communication to other healthcare professionals and ensures proper follow-up care. Administering O2 therapy (B) or albuterol (D) without a clear understanding of the underlying issue could be harmful. Positioning the client in high-Fowler's position (C) may not directly address the potential emergency at hand.