The nurse assesses the client four hours after a chest tube insertion for a pneumothorax. Which does the nurse expect after an uncomplicated chest tube insertion into the client's thorax?

Question

1. Radiating chest pain
2. Bilateral breath sounds
3. Bloody pleural drainage
4. Uneven lung expansion

Answer 1

2
2. The nurse expects to auscultate bilateral breath sounds after an uncomplicated chest tube insertion, indicating both lungs are ventilating, even if one lung remains partially collapsed.
1. Radiating chest pain is an unexpected and troubling client assessment; the chest pain warrants further investigation by the nurse.
3. The nurse expects pleural drainage to diminish after the first few hours of chest tube insertion, indicating that healing and hemostasis are beginning.
4. Asymmetrical lung expansion is consistent with clinical indicator that the client has a major portion of nonventilating lung; this warrants further investigation by the nurse because a major disproportion between the lungs potentially leads to tension pneumothorax if the difference is due to fluid drainage.