MSNCB Medical-Surgical Nursing Exam Prep

Category - Medical Surgical

Two hours ago the client had a left thoracotomy with a lobe resection. The sanguineous drainage in the chest tube collection chamber is 325 mL. The nurse recognizes that this is:
  1. Normal chest tube drainage
  2. Indicative of a pneumothorax
  3. Chyle drainage
  4. A sign of hemorrhage
Explanation
Answer - D - Sanguineous drainage of greater than 100 mL/hr in the client who is in the immediate postoperative period following a thoracotomy indicates hemorrhage. The physician should be notified immediately. Normal chest tube drainage should be less than 100 mL/hr. A pneumothorax occurs when there is air between the visceral and the parietal pleura, which causes compression of the lung and results in acute respiratory distress. Chyle drainage is a milky color that results from disruption of the lymphatic drainage system.
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