The Assessment Patient Process
The Assessment Patient Process ( 6 Questions)
A nurse is caring for a client who has a chest tube connected to a water seal drainage system.
Which action should the nurse take to ensure proper functioning of the system?
This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax or impair lung re-expansion. The nurse should only clamp the chest tube briefly when changing the drainage system or when ordered by the provider.
Keeping the drainage system below the level of the client's chest prevents backflow of fluid into the pleural space and maintains negative pressure in the system.
This is an incorrect action, as emptying the drainage chamber can disrupt the water seal and allow air to enter the pleural space. The nurse should only empty the drainage chamber when it is full or when changing the system.
This is an incorrect action, as adding sterile water to the suction control chamber can increase or decrease the amount of suction applied to the chest tube, depending on whether water is added or removed. The nurse should only add sterile water to the water seal chamber if it falls below the 2 cm mark.
Keep the drainage system below the level of the client's chest.
Rationale: Keeping the drainage system below the level of the client's chest prevents backflow of fluid into the pleural space and maintains negative pressure in the system.
Incorrect options:
A) Clamp the chest tube periodically to check for air leaks. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax or impair lung re-expansion. The nurse should only clamp the chest tube briefly when changing the drainage system or when ordered by the provider.
C) Empty the drainage chamber when it is half full. - This is an incorrect action, as emptying the drainage chamber can disrupt the water seal and allow air to enter the pleural space. The nurse should only empty the drainage chamber when it is full or when changing the system.
D) Add sterile water to the suction control chamber as needed. - This is an incorrect action, as adding sterile water to the suction control chamber can increase or decrease the amount of suction applied to the chest tube, depending on whether water is added or removed. The nurse should only add sterile water to the water seal chamber if it falls below the 2 cm mark.