NCLEX-PN

Category - Physiological Adaptation

A nurse is assigned to monitor the chest tube drainage system of a client with pneumothorax. The nurse should immediately call the RN if which of the following observations is noted?
  1. Intermittent bubbling in the water seal chamber
  2. Oscillation in the water seal chamber is observed
  3. Volume in the drainage system increases from 100 to 300 ml in an hour
  4. Volume in the drainage system increases from 100 to 150 ml in an hour
Explanation
Answer: C - An increase of more than 100 ml in the drainage system in an hour’s time should be reported to the RN or physician. The other observations are normal and expected.
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