13. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?

A. Ambulate the client in the hallway to promote deep breathing.
B. Auscultate the client's anterior and posterior lung fields.
C. Encourage the client to take shallow breaths to help with the pain.
D. Administer pain medication and encourage the client to take deep breaths.

For a client who had a chest tube placed six hours ago and is refusing to take deep breaths due to the pain, the nurse should administer pain medication and encourage them to take deep breaths. This is because deep breathing helps maintain lung expansion and clear trapped air/mucus in lungs. Adequate pain management can facilitate this.

Explanation:

The nurse should choose option D: Administer pain medication and encourage the client to take deep breaths. The client refusing to take deep breaths due to pain can lead to further complications such as respiratory issues like atelectasis, the collapse of part or all of a lung, or pneumonia. Having a chest tube in does cause discomfort, but adequate pain control and assurance can facilitate deep breathing. Deep breaths are important to help maintain lung expansion and clear mucus/trapped air in the lungs, necessary after chest tube placement. The nurse may have to work alongside the treating physician to ensure the patient's pain is well controlled, and this fostering of deep breaths can take place.

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