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NCLEX-PN Exam Practice

Category - Respiratory

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You have assisted the physician with insertion of a chest tube. As you monitor the fluid level in the water seal chamber you notice fluctuations in the fluid. What is the appropriate action?

Notify the physician.
Encourage the patient to deep breathe.
This is a normal finding.
Reinforce the dressing.

Explanation

Answer: C - Fluctuations of the fluid in the water seal chamber is a normal finding and the nurse should do nothing at this point. The water levels will rise and fall with the patient’s breathing pattern. The fluctuations will stop if the tube is obstructed, if suction is not working or if the lung is reexpanded.

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