The Nurse Is Performing an Initial Assessment of a Patient

question 28

Multiple Choice

The nurse is performing an initial assessment of a patient with a chest tube placed in the eighth intercostal space.Which of the following findings would the nurse need to assess further? (Select all that apply. )

• A)Respiratory rate of 18 breaths per minute
• B)Continuous bubbling in the water-seal chamber
• C)The presence of subcutaneous emphysema
• D)Complaints of pain at the insertion site
• E)Serous drainage on the chest tube dressing the size of a bean

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