Which action would the nurse take first for a patient with a tracheostomy who appears anxious and is having difficulty in coughing up thick respiratory secretion?

A. Discharge immediately following an open lung biopsy is unlikely. The patient will need observation post-procedure for complications such as bleeding, infection, or pneumothorax, and it usually requires a stay in the hospital for monitoring.
B. It is unlikely that supplemental oxygen will not be needed following an open lung biopsy. The patient may require oxygen post-procedure due to potential respiratory compromise, such as atelectasis or pneumothorax.
C. A chest tube is commonly inserted after an open lung biopsy to allow the lung to re-expand and to drain air or fluid that may accumulate in the pleural space. This is a standard part of the postoperative care for this procedure.
D. Collecting a sputum specimen is not typically necessary immediately after an open lung biopsy. The focus will be on monitoring the patient’s respiratory status, ensuring proper lung expansion, and preventing complications like pneumothorax or bleeding.

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.