The nurse is caring for a client who had a thoracotomy 1 hour ago and reports incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which of thefollowing actions is best for the nurse to take next?
A)Administer the prescribed PRN morphine.
B)Assist the client to deep breathe and cough.
C)Milk the chest tube gently to remove any clots.
D)Tape the area around the insertion site of the chest tube.

Question

Quizplus · Accepted Answer

The client is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.

The Nurse Is Caring for a Client Who Had a Thoracotomy