NCLEX Question for subcutaneous emphysema

NCLEX Review Question

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?

a.Record the observation.
b.Apply a compression dressing to the area.
c.Measure the patient's pulse oximetry.
d.Report the finding to the physician immediately.

Correct Answer: A
Record the observation.
Rationale:
Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Apply a compression dressing to the area.
Rationale: Subcutaneous emphysema is a typical post-operative finding in the patient after chest surgery.

Measure the patient's pulse oximetry.
Rationale: Subcutaneous emphysema is absorbed by the body spontaneously after the underlying leak is treated or halted.

Report the finding to the physician immediately.
Rationale: Subcutaneous emphysema results from air entering the tissue planes.

Posted in: MSN NCLEX