A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select 2 manifestations that apply.)

A. Pain at the insertion site: Mild to moderate pain is expected after chest tube placement and should be monitored, but it does not usually require immediate intervention unless it worsens or becomes severe. It is typically managed with routine analgesics. B. Tracheal deviation: Tracheal deviation is a late and critical sign of tension pneumothorax, which requires immediate emergency intervention. It indicates severe pressure in the pleural space that can compress major vessels and impair cardiac output. C. Drainage of 75 mL/hr: While slightly elevated, this drainage rate may be acceptable depending on the clinical context (e.g., post-thoracic surgery). The nurse should continue monitoring, but this does not require immediate action unless drainage exceeds 100–150 mL/hr. D. Productive sputum: Productive sputum is not unusual in patients with underlying pulmonary conditions. Unless it is accompanied by signs of infection or changes in sputum color, amount, or consistency, it does not warrant immediate action. E. Sudden onset of shortness of breath: A sudden change in respiratory status may indicate a complication such as tube dislodgement, blockage, or recurrent pneumothorax. This requires prompt evaluation and intervention to ensure adequate oxygenation and ventilation.