A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Raise the drainage system to the client's chest level.

Clamp the tubing to check for air leaks.

Empty the collection chamber.

Gently squeeze the tubing to remove excess drainage.

Answer and Explanation

The Correct Answer is B

B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.

A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.

C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.

D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.

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Correct Answer is D

Explanation

D. This practice is recommended to maintain catheter patency and prevent occlusion.

A Changing the transparent membrane dressing is typically done every 5 to 7 days, not daily, unless it's soiled or compromised.

B. Accessing the catheter with a non-coring needle is not applicable in this context as PICC lines are already in place and do not require such needles for access.

C. Maintaining a continuous IV infusion is not necessary for a client receiving intermittent IV bolus medication and could increase the risk of complications without providing any benefit in this scenario.

A. "Suction pressure that is too high causes this." B. "Your breathing pattern causes this." C. "This indicates a possible air leak." D. "This means your lung is fully re-expanded."

Correct Answer is B

Explanation

B. Changes in the fluid level of the water-seal chamber correspond to the client's breathing pattern. During inhalation, the negative pressure in the chest cavity may cause the fluid level to rise slightly as air is drawn into the tube, and during exhalation, the fluid level may fall as air exits through the chest tube.

A Fluctuations in the fluid level can occur due to changes in suction pressure settings, but this is more relevant to the suction control chamber rather than the water-seal chamber.

C. If there is continuous bubbling in the water-seal chamber, it indicates an air leak, which disrupts the normal function of the water-seal mechanism.

D. The water-seal chamber's fluctuation does not directly indicate lung re-expansion. Lung re-expansion is assessed through clinical examination, chest X-ray, or other diagnostic tests rather than the water-seal chamber.

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A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take?

Nursing Test Bank

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Explanation

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