The Nurse Is Performing an Initial Assessment of a Patient

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