NCLEX-RN

Category - Physiological

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A nurse assesses the chest tube drainage system of a client with pneumothorax. An immediate action is needed if which of the following observations is noted by the nurse?

The volume in the drainage system increases from 200 ml to 400 ml in an hour.
Gentle bubbling is noted in the suction control chamber.
The water in water seal chamber moves up as the client inhales and moves down as the client exhales.
Intermittent water bubbling is noted in the water seal chamber.

Explanation

Answer: A - An increase of greater than 100 ml of drainage per hour should be reported to the physician. In a client with pneumothorax, intermittent water bubbling in the water seal chamber is expected. The other observations are also expected.

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