A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Sudden onset of shortness of breath
d. Pain at insertion site
e. Drainage of 75 mL/hr
ANS: B, C
Tracheal deviation and sudden onset of shortness of breath are manifestations of a tension pneumothorax. The nurse must intervene immediately for this emergency situation. Pink sputum is associated with pulmonary edema and is not a complication of a chest tube. Pain at the insertion site and drainage of 75 mL/hr are normal findings with a chest tube.
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