HESI Registered Nurse EXIT Practice Exam

What complication should the nurse monitor for in a client with a recent chest tube insertion?

1. Infection

2. Pneumothorax

3. Fluid overload

4. Subcutaneous emphysema

The correct answer is: Infection

Monitoring for infection is crucial for a client who has had a recent chest tube insertion. The procedure involves breaking the skin barrier, which can introduce bacteria and potentially lead to an infection. The nurse should assess the insertion site for signs such as redness, swelling, warmth, and drainage, as well as consider systemic signs of infection like fever or increased white blood cell count. While complications such as pneumothorax, fluid overload, and subcutaneous emphysema are also important to monitor for after chest tube placement, they are not as immediate or expected as the risk for infection. Pneumothorax can occur if the tube is improperly placed, fluid overload may occur with excessive fluid administration or inadequate monitoring of fluid balance, and subcutaneous emphysema involves air escaping into subcutaneous tissue, which typically follows specific types of trauma or procedural errors. Therefore, in the context of immediately following chest tube insertion, the most critical complication to monitor for is infection.