Difficulty: Medium
Average Score: 72%
Simulated
A nurse is caring for a client who has a three-chamber chest tube system. Which of the following actions should the nurse take?
Correct answer
A
Rationale
The correct answer is A: Ensure 2 cm (0.8 in) of water is in the water seal chamber. This is important to create a seal that prevents air from entering the pleural space. If the water level is too high or too low, it can affect the functioning of the chest tube system.
Choice B is incorrect as checking tubing patency every 2 hours is not necessary unless there are signs of blockage or decreased drainage.
Choice C is incorrect as the drainage system should be kept below the level of the client's chest to facilitate drainage by gravity.
Choice D is incorrect as the collection chamber should be emptied as needed based on the amount of drainage, not on a fixed time schedule.
Choice B is incorrect as checking tubing patency every 2 hours is not necessary unless there are signs of blockage or decreased drainage.
Choice C is incorrect as the drainage system should be kept below the level of the client's chest to facilitate drainage by gravity.
Choice D is incorrect as the collection chamber should be emptied as needed based on the amount of drainage, not on a fixed time schedule.