For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?
a. Measuring and documenting the drainage in the collection chamber
b. Maintaining continuous bubbling in the water-seal chamber
c. Keeping the collection chamber at chest level
d. Stripping the chest tube every hour
Answer A.
The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse should not strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
a. Measuring and documenting the drainage in the collection chamber
b. Maintaining continuous bubbling in the water-seal chamber
c. Keeping the collection chamber at chest level
d. Stripping the chest tube every hour
Answer A.
The nurse should measure and document the amount of chest tube drainage regularly to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse should not strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
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Respiratory