Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
A. Inform the physician.
B. Continue to monitor the client.
C. Reinforce the occlusive dressing.
D. Encourage the client to deep breathe.
Correct Answer: B. Continue to monitor the client.
The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re-expanded.
Option A: Monitor water-seal chamber “tidaling.” Note whether the change is transient or permanent. The water-seal chamber serves as an intrapleural manometer (gauges intrapleural pressure); therefore, fluctuation (tidaling) reflects pressure differences between inspiration and expiration.
Option C: If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify the physician at once. Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment.
Option D: Assist the patient with splinting painful areas when coughing, deep breathing. Supporting chest and abdominal muscles makes coughing more effective and less traumatic.
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