Documentation and Reporting
Documentation and Reporting ( 6 Questions)
A nurse is caring for a client who has a chest tube connected to a water seal drainage system. The nurse observes continuous bubbling in the water seal chamber.
Which of the following actions should the nurse take?
This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and other structures. The nurse should only clamp the chest tube briefly when changing the drainage system or assessing for an air leak.
The nurse should check the tubing for any leaks or kinks, as continuous bubbling in the water seal chamber indicates an air leak in the system, which can impair lung re-expansion and drainage. The nurse should locate and seal the leak, and notify the provider if necessary.
This is an incorrect action, as increasing the suction pressure to the drainage system can cause damage to the lung tissue and increase the risk of infection. The nurse should follow the provider's prescription and the manufacturer's guidelines for setting and adjusting the suction pressure.
This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document the finding as an abnormal finding and report it to the provider.
Check the tubing for any leaks or kinks.
Rationale: The nurse should check the tubing for any leaks or kinks, as continuous bubbling in the water seal chamber indicates an air leak in the system, which can impair lung re-expansion and drainage. The nurse should locate and seal the leak, and notify the provider if necessary.
Incorrect options:
A) Clamp the chest tube near the insertion site. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and other structures. The nurse should only clamp the chest tube briefly when changing the drainage system or assessing for an air leak.
C) Increase the suction pressure to the drainage system. - This is an incorrect action, as increasing the suction pressure to the drainage system can cause damage to the lung tissue and increase the risk of infection. The nurse should follow
the provider's prescription and the manufacturer's guidelines for setting and adjusting the suction pressure.
D) Document the finding as an expected outcome. - This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document
the finding as an abnormal finding and report it to the provider.