A nurse is caring for a client diagnosed with lung carcinoma and scheduled for a left pneumonectomy. The nurse should prioritize which nursing Intervention in the immediate postoperative period?

A. Hypotension: While hypotension can occur in clients with acute respiratory failure (ARF), it is not a primary manifestation of the condition. Hypotension may arise due to other factors, such as sepsis or significant fluid loss, but is not universally present in ARF. Therefore, it is less likely to be a key finding in this context.
B. Severe dyspnea: This is a hallmark manifestation of ARF. Clients typically experience significant difficulty in breathing due to inadequate oxygenation or ventilation, leading to an urgent need for medical intervention. Monitoring for severe dyspnea is critical as it directly indicates the severity of respiratory distress.
C. Headache: Headaches can be a manifestation of acute respiratory failure, particularly due to hypoxia or hypercapnia (elevated carbon dioxide levels) affecting cerebral circulation. This symptom may arise as the body struggles to compensate for decreased oxygen levels, making it important to monitor in clients with ARF.
D. Decreased level of consciousness: This is a significant concern in ARF and can indicate worsening hypoxia or hypercapnia. Alterations in consciousness may range from confusion to unresponsiveness and require immediate evaluation and intervention, making it a critical manifestation to monitor.
E. Nausea: Although some clients may experience nausea as a secondary symptom due to anxiety or as a response to hypoxia, it is not a primary or definitive manifestation of acute respiratory failure. Therefore, while it may occur in some cases, it is not one of the key findings to consistently monitor in clients with ARF.

• Assess for subcutaneous emphysema: Assessing for subcutaneous emphysema is crucial because it can indicate that air is escaping into the subcutaneous tissue, often resulting from a significant air leak. Early detection of subcutaneous emphysema allows for timely intervention, which is essential to manage the complication effectively and prevent further respiratory compromise.
• Check the drainage system and tubing: Checking the drainage system and tubing is important to ensure that the chest tube and drainage system are functioning correctly. This includes identifying any kinks, disconnections, or leaks in the tubing that could contribute to the air leak. Ensuring the integrity of the drainage system is vital for effective management of the client’s respiratory condition and for restoring proper lung expansion.
• Obtain blood cultures: This action is not indicated in this scenario unless there are signs of infection. The client’s symptoms do not suggest an infection requiring cultures at this time. Blood cultures would be more appropriate if there were signs of systemic infection, such as fever or elevated white blood cell count.
• Administer prescribed blood products: This action is also not appropriate unless there is evidence of significant bleeding or anemia. The client’s hemoglobin levels are within normal limits, so this intervention is not necessary.
• Observe surgical dressing: While important for monitoring the integrity of the surgical site, this action is not the priority when assessing for an air leak. Observing the dressing can help identify signs of drainage or infection but should follow the assessment for subcutaneous emphysema and the examination of the drainage system.
• Respiratory status: Monitoring the client's respiratory status is crucial for assessing lung function and detecting any changes in breathing patterns, oxygen saturation, or the presence of respiratory distress. Given the client's recent thoracotomy, careful observation can help identify complications early.
• Chest tube drainage: Assessing chest tube drainage is important to monitor the amount and type of fluid draining from the chest, as well as to identify any changes that may indicate bleeding or other complications. The 50 mL of sanguineous drainage noted since 0700 should be tracked to ensure it remains within acceptable limits and does not indicate excessive bleeding.
• Client's ability to perform lung expansion exercises: While important for overall respiratory health, monitoring the client’s ability to perform lung expansion exercises is not as critical in the context of an acute air leak. However, encouraging lung expansion exercises can help prevent complications such as atelectasis.
• Sputum: Monitoring sputum can provide information about respiratory status and potential infections. In this case, assessing sputum may be relevant but is secondary to monitoring respiratory status and chest tube drainage.
• Blood pressure: Blood pressure is important to monitor but is not the primary focus in the context of chest tube management and respiratory issues. Monitoring blood pressure can provide information about the client’s overall hemodynamic stability but is not directly related to assessing the air leak.
• Bleeding: While the client has some sanguineous drainage, the amount (50 mL) is not excessive, and hemoglobin levels are within normal limits. There are no signs of significant hemorrhage, making bleeding a less likely primary condition.
• Pulmonary edema: Pulmonary edema typically presents with symptoms such as dyspnea, cough with frothy sputum, and hypoxia. The client's symptoms and findings do not support a diagnosis of pulmonary edema, which is more commonly associated with heart failure.
• Pneumonia: While pneumonia can present with respiratory distress and abnormal lung sounds, the absence of fever and the clear sputum do not strongly indicate this condition in the current scenario. The findings are more consistent with an air leak.
• Air leak: The presence of tidaling in the water seal chamber along with continuous bubbling in the chest tube drainage system suggests an air leak. Continuous bubbling indicates that air is escaping into the pleural space, which can compromise lung expansion and lead to respiratory complications. This situation necessitates immediate attention to prevent further respiratory distress.