A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?

Inform the health care provider that there is a probable leak in the drainage system.

Encourage the client to breathe deeply so the water seal will stabilize.

Inform the health care provider that the client is ready to have the chest tube removed.

Document that the chest drainage system is functioning as intended.

Answer and Explanation

The Correct Answer is D

A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.

B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.

C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.

D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.

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Correct Answer is D

Explanation

A. Empty the drainage from the pleuravac at the end of each shift: This is not a standard practice. Chest tube drainage systems typically have a built-in mechanism to handle drainage, and monitoring and recording the output is essential.

B. Report serosanguinous drainage in the pleuravac: Serosanguinous drainage (a mix of blood and serous fluid) can be expected in a hemothorax, especially initially. Reporting is necessary if there are significant changes in the amount or type of drainage.

C. Milk the chest tube every 4 hours to dislodge clotted blood: Milking or stripping the chest tube is generally not recommended as it can create high negative pressures that can damage lung tissue.

D. Assist with coughing and deep breathing exercises every hour: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion, which is crucial for recovery from a hemothorax.

A. Obtain pulse oximetry every two hours. B. Teach the client how to use the incentive spirometer. C. Instruct the client to practice abdominal breathing. D. Encourage oral fluid intake of 2000 mL/24 hours.

Correct Answer is B

Explanation

A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.

B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.

C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.

D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.

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A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?

Correct Answer is D

Explanation

A nurse is caring for a client following a left lobectomy for lung cancer. The nurse should prioritize which of the following interventions to prevent atelectasis?

Correct Answer is B

Explanation

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