The nurse is caring for a client with a left pneumothorax and a water-seal chest tube. Which of the following indicates a need for further action by the nurse?
The client is resting in a semi-Fowler’s position.
The client is resting in a Trendelenburg’s position.
The suction control chamber has constant gentle bubbling.
Constant bubbling is present in the water seal after clamping off suction.
Tidaling is present in the water seal chamber and corresponds to respiration.
Numbers 2 and 4 are correct.
Rationale: A client with a chest tube should not be placed in a Trendelenburg’s position as this will prevent drainage from going into the chest tube drainage device. Constant bubbling in the water seal after clamping off suction indicates an air leak. The nurse should check and tighten all connections and check the tubing for a leak. If a leak is noted in the tubing, replace the drainage device. Check the insertion site by removing the dressing and verifying that the chest tube eyelets are not visible. If no leaks can be seen or heard at the insertion site, the lung is the source of the leak. If the leak persists after troubleshooting, notify the health care provider. A semi-Fowler’s position is appropriate and facilitates drainage into the drainage system. Constant gentle bubbling in the suction control chamber and tidaling in the water seal chamber that corresponds to respiration are expected findings.
