A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective?

The correct answer is Choice A

Choice A rationale: Movement of the trachea toward the unaffected side indicates a possible tension pneumothorax, which is a life-threatening condition. This shift occurs due to the increased pressure on the affected side, pushing the trachea away. Immediate intervention is required.

Choice B rationale: Crepitus, or subcutaneous emphysema, can be a common finding around the chest tube insertion site. It indicates air leakage into the subcutaneous tissue but does not necessarily require immediate notification to the provider unless it is extensive or worsening.

Choice C rationale: Bubbling of the water in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning properly by allowing air to escape from the pleural space. This is a normal finding in pneumothorax management.

Choice D rationale: The visibility of eyelets on the chest tube indicates that the tube is in the correct position within the pleural space. If the eyelets are not visible, it means the tube is not functioning correctly, but this is not as urgent as a tracheal shift.

Choice A reason: Recording the client's intake and output is important but not the highest priority in an unconscious patient following a cerebral hemorrhage.

Choice B reason: Performing passive range of motion exercises is a lower priority compared to maintaining a patent airway.

Choice C reason: Suctioning saliva from the client's mouth is the highest priority to maintain airway patency and prevent aspiration, which is critical for an unconscious patient.

Choice D reason: Monitoring the client's electrolyte levels is important but secondary to immediate life-saving interventions such as maintaining airway patency.