Difficulty: Medium
Average Score: 62%
Simulated
The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What intervention should the nurse implement?
Correct answer
D
Rationale
Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate occlusion of the tubing or that the lung has reexpanded. Excessive bubbling in the water seal chamber indicates that an air leak is present.