One hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 50 mLs of bloody drainage, and the nurse observes fluctuation in the water seal chamber. Which action should the nurse take?
Administer pain medication as prescribed.
Notify the healthcare provider immediately.
Reposition the patient to the unaffected side.
Document the findings and continue to monitor the drain.
The Correct Answer is A
A. Administering pain medication is the priority action in this scenario. The patient is experiencing significant post-surgical pain, which can impair their ability to breathe deeply and effectively. Addressing pain will improve comfort and facilitate better respiratory effort.
B. Notifying the healthcare provider immediately is not warranted based on the current findings. The amount of drainage (50 mL) is within expected limits for the first hour after surgery, and fluctuation in the water seal chamber indicates the chest tube is functioning properly.
C. Repositioning the patient to the unaffected side may help with comfort but is not the most appropriate action to address the pain or improve respiratory status in this situation.
D. Documenting the findings and continuing to monitor the drain is important but does not address the patient’s immediate need for pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. If there is no fluctuation in the water seal compartment, the first action should be to check for kinks, obstructions, or other issues in the tubing that might block air or fluid movement. Fluctuation (tidaling) is expected during respiration, and its absence may indicate a problem with the system or that the lung has fully re-expanded.
B. Notifying the healthcare provider immediately is not the first step. The nurse should first assess the chest tube system to determine if there is an issue that can be resolved without medical intervention.
C. Increasing the suction pressure on the chest tube is not appropriate without first identifying the cause of the lack of fluctuation. Adjusting suction may not address the underlying problem.
D. Continuing to monitor and reassess in 1 hour delays addressing the potential issue. Immediate assessment of the chest tube system is necessary to ensure proper functioning.
Correct Answer is C
Explanation
A. Clamping the chest tube near the water seal is not recommended because it can lead to complications such as a tension pneumothorax. The chest tube should remain unclamped unless instructed by the healthcare provider.
B. Repositioning the client may be necessary if the rise in the water seal chamber is due to a physical obstruction or positioning issue. However, this is not the first action to take.
C. A rise in the water seal chamber with inspiration (tidal fluctuation) is a normal finding in a chest tube system. It indicates that the lung is re-expanding and that the pleural space is still connected to the atmosphere. The nurse should continue to monitor the client and the chest tube system for any other changes.
D. Immediate notification of the provider is not necessary unless there are other signs of complications, such as sudden changes in the drainage amount, a lack of fluctuation, or signs of respiratory distress.
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