Exhibits

The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.

Complete the following sentence by choosing from the lists of options.

Based on the information collected, the client is likely experiencing

 related to

A. A chest x-ray can be useful to assess for complications or changes in lung status, such as pneumothorax, pleural effusion, or changes in lung volume. However, the change in drainage color from viscous green to clear watery fluid may not immediately warrant an x-ray unless there are additional clinical concerns or symptoms suggesting a need for imaging.
B. Continuing the IV antibiotic schedule is important if there is an ongoing infection that needs treatment. However, if the change in drainage is significant and suggests a potential change in the underlying condition or complication, it’s important to evaluate the cause of the change rather than solely relying on antibiotics.
C. Obtaining a specimen of the drainage for culture is a valuable action if there is concern about infection or if the drainage characteristics have changed unexpectedly. Clear, watery fluid could indicate the presence of serous fluid or a change in the nature of the drainage, potentially due to infection or resolution of an infection.
D. “Milking” or stripping the chest tube is not recommended as a routine practice because it can create negative pressure and potentially damage the pleural tissues or exacerbate issues. Additionally, the change in the drainage from viscous green to clear watery fluid does not necessarily indicate that clots are present or that tube milking would be helpful.

A. The surgical consent form is crucial for ensuring that the client is informed about the procedure and agrees to it. While it's critical for legal and ethical reasons, this issue can often be resolved relatively quickly by having the client sign the form or addressing it with the surgeon.
B. A pulse oximeter reading of 96% indicates that the client's oxygen saturation is within a generally acceptable range (normal is usually 95% to 100%). This reading suggests that the client's oxygen levels are adequate and typically would not require immediate action.
C. The absence of a preoperative chest x-ray report can be significant, especially if the client has underlying respiratory or cardiac conditions. However, the immediate need for action depends on the urgency and the reason the x-ray was ordered.
D. A serum potassium level of 2.8 mEq/L is critically low. The normal reference range is 3.5 to 5 mEq/L. Hypokalemia (low potassium) can lead to severe complications, including cardiac arrhythmias and muscle weakness, which can significantly impact the client's ability to safely undergo surgery. This condition requires immediate attention to correct the electrolyte imbalance before proceeding with the surgical procedure.