A nurse is caring for an adult client.

Exhibits

The nurse should determine the assessment findings are consistent with which of the following disease processes?

For each assessment finding, click to specify if the assessment finding is consistent with laryngotracheobronchitis (LTB), epiglottitis, or foreign body aspiration. Each finding may support more than 1 disease process.

• 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.

A. "I feel frustrated when you interrupt me. It's important for us to take turns speaking during client discussions." This response demonstrates assertive behavior because it expresses the nurse's feelings directly and respectfully while addressing the specific behavior that is problematic. By focusing on "I feel" statements, the nurse communicates personal feelings without blaming or attacking the colleague. This approach encourages a constructive dialogue and promotes a more collaborative working relationship.
B. "If you keep interrupting me, I'll report you to our supervisor for disciplinary action." This response is not assertive; it is more aggressive and threatening. It shifts the focus from the behavior to a punitive action and can escalate conflict rather than fostering a constructive conversation. It may create defensiveness in the colleague and is unlikely to resolve the underlying issue.
C. "You always interrupt me when I'm talking. Can't you see how disrespectful that is?" This response is accusatory and confrontational, which is not assertive behavior. While it addresses the behavior, it does so in a way that may cause the colleague to become defensive or hostile. Effective assertiveness involves expressing feelings and needs without assigning blame or using harsh language.
D. "I can't work with someone who constantly takes over conversations. You need to find another partner." This statement is dismissive and aggressive, effectively shutting down communication rather than encouraging teamwork. It does not allow for resolution or discussion of the behavior, making it counterproductive in promoting effective collaboration. Assertive communication should focus on addressing issues while maintaining a willingness to work together.