Nclexrn Quiz: Chest Tube Monitoring And Troubleshooting
20 questions · exam conditions
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Chest Tube Monitoring And TroubleshootingQuestion 1 of 20

A 72-year-old client has a chest tube for pleural effusion. The nurse notes erythema and warmth at the insertion site with purulent drainage; VS: T 38.6 C (101.5 F), HR 110, BP 118/70, SpO2 94% on 2 L NC. Which intervention should the nurse implement to prevent infection?

Change the dressing using sterile technique and perform hand hygiene before and after care
Milk the chest tube every 2 hr to prevent clot formation
Apply petroleum gauze around the tube and leave the dressing open to air
Delegate assessment of the insertion site to the UAP each shift
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Nclexrn Quiz: Chest Tube Monitoring And Troubleshooting

Practice Chest Tube Monitoring And Troubleshooting in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Chest Tube Monitoring And Troubleshooting, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

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Question 1

A 72-year-old client has a chest tube for pleural effusion. The nurse notes erythema and warmth at the insertion site with purulent drainage; VS: T 38.6 C (101.5 F), HR 110, BP 118/70, SpO2 94% on 2 L NC. Which intervention should the nurse implement to prevent infection?

  1. Change the dressing using sterile technique and perform hand hygiene before and after care (correct answer)
  2. Milk the chest tube every 2 hr to prevent clot formation
  3. Apply petroleum gauze around the tube and leave the dressing open to air
  4. Delegate assessment of the insertion site to the UAP each shift
Explanation: This question tests chest tube monitoring and troubleshooting skills, specifically infection prevention at the chest tube insertion site. The key assessment findings are signs of infection including erythema, warmth, purulent drainage, and fever (38.6°C), requiring proper wound care interventions. Changing the dressing using sterile technique and performing hand hygiene before and after care (A) is the correct intervention because it follows infection control principles and prevents further contamination. Milking the chest tube (B) is contraindicated as it can cause tissue damage and increased negative pressure, applying petroleum gauze with an open dressing (C) would not properly protect the site from contamination, and delegating insertion site assessment to UAP (D) is inappropriate as this requires nursing assessment skills. The fundamental principle is that chest tube insertion sites require meticulous sterile technique and regular assessment to prevent and manage infections, which can lead to empyema or sepsis. When caring for chest tube sites with signs of infection, always use strict sterile technique, obtain cultures as ordered, and monitor for systemic infection while maintaining the integrity of the drainage system.

Question 2

A 63-year-old client has a chest tube for hemothorax. VS: HR 116, RR 26, BP 88/52, SpO2 91% on 6 L/min simple mask; drainage is 250 mL of dark red blood in the last 30 min. Which assessment finding indicates a complication with the chest tube?

  1. Drainage of 250 mL in 30 min with hypotension and increasing tachycardia (correct answer)
  2. No bubbling in the water-seal chamber when the client is resting quietly
  3. Tidaling noted in the water-seal chamber with respirations
  4. Serosanguineous drainage of 30 mL in the last hour
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key assessment findings include rapid drainage of dark red blood with signs of shock like hypotension and tachycardia. The finding of 250 mL drainage in 30 minutes with hypotension and tachycardia best indicates a complication, as it suggests hemorrhage. No bubbling at rest (B) can be normal if the hemothorax is resolving, tidaling (C) is expected, and 30 mL serosanguineous drainage (D) is typical. Excessive output signals ongoing bleeding that may require surgical intervention. The rationale is monitoring for drainage exceeding 200 mL/hour to prevent hypovolemia. A transferable strategy is to correlate drainage trends with vital signs for early detection of bleeding.

Question 3

A 57-year-old client has a chest tube for hemothorax. VS: HR 112, RR 24, BP 98/58, SpO2 93% on 4 L/min nasal cannula; drainage is 220 mL/hr of bright red blood for 2 consecutive hours. What is the nurse's PRIORITY action?

  1. Notify the provider of excessive output and continue frequent VS and drainage monitoring (correct answer)
  2. Lower suction to -10 cm H2O to reduce the amount of drainage
  3. Flush the chest tube with sterile saline to prevent clot formation
  4. Document the output and reassess in 4 hr if the client remains stable
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key assessment findings include sustained high drainage with instability indicating need for escalation. Notifying the provider of excessive output and continuing monitoring is the best action, as it prompts intervention. Lowering suction (B) may not control bleeding, flushing (C) is contraindicated, and documenting without action (D) is inadequate. Persistent high output signals complication. The rationale is early reporting prevents shock. A transferable strategy is to trend drainage and vital signs hourly.

Question 4

A 67-year-old client has a chest tube placed for a left hemothorax after a motor vehicle crash. VS: HR 122, RR 28, BP 92/56, SpO2 89% on 10 L/min nonrebreather; chest tube drainage is 350 mL of bright red blood in the last hour. Which assessment finding indicates a complication with the chest tube?

  1. Tidaling present in the water-seal chamber with inspiration and expiration
  2. Drainage of 350 mL bright red blood in 1 hr with worsening tachycardia (correct answer)
  3. Small intermittent bubbling in the water-seal chamber when the client coughs
  4. Serosanguineous drainage totaling 200 mL over the last 8 hr
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key assessment findings include excessive bright red drainage with signs of hemodynamic instability like tachycardia and hypotension, indicating potential hemorrhage. The finding of 350 mL bright red blood in 1 hour with worsening tachycardia is the best indicator of a complication, as it suggests active bleeding requiring immediate intervention. Tidaling (A) is normal, small intermittent bubbling with coughing (C) is expected in hemothorax, and 200 mL serosanguineous drainage over 8 hours (D) is within normal limits post-trauma. Excessive drainage can lead to hypovolemic shock if not addressed promptly. The rationale is that chest tube output greater than 200-300 mL/hour signals a complication like vascular injury. A transferable strategy is to monitor drainage volume, color, and vital signs hourly in the initial postoperative period to detect complications early.

Question 5

A 59-year-old client is 12 hr post-thoracic surgery with a chest tube for pneumothorax. VS: HR 96, RR 18, BP 124/70, SpO2 95% on 2 L/min nasal cannula; drainage is 60 mL serosanguineous over 4 hr. Continuous bubbling is present in the water-seal chamber. What is the nurse's PRIORITY action if an air leak is suspected?

  1. Notify the provider after documenting the amount and color of drainage
  2. Assess the tubing connections and insertion-site dressing for loose seals (correct answer)
  3. Add sterile water to the suction-control chamber until bubbling stops
  4. Increase oxygen flow and obtain a full set of vital signs
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key assessment findings include continuous bubbling in the water-seal chamber post-thoracic surgery, suggesting a possible system air leak. Assessing tubing connections and insertion-site dressing for loose seals is the best action, as it identifies and corrects external leaks. Notifying the provider without assessment (A) delays troubleshooting, adding water to the suction chamber (C) addresses the wrong chamber, and increasing oxygen (D) treats symptoms but not the cause. Continuous bubbling can indicate a breach in the closed system, leading to ineffective drainage. The principle is to ensure system integrity for proper pleural evacuation. A transferable strategy is to inspect all connections and dressings first when bubbling is abnormal.

Question 6

A 41-year-old client with a chest tube for pneumothorax after thoracic surgery suddenly reports dyspnea. VS: HR 118, RR 30, BP 146/84, SpO2 86% on 6 L/min nasal cannula; the chest tube has become dislodged from the insertion site and air is heard entering the wound. What is the nurse's IMMEDIATE action?

  1. Apply a sterile occlusive dressing taped on three sides over the insertion site (correct answer)
  2. Place the client in high-Fowler position and reassess SpO2 in 5 min
  3. Clamp the remaining tubing and notify the provider
  4. Ask the assistive personnel to obtain a portable chest x-ray
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key interventions include immediate coverage of the dislodged chest tube site to prevent air entry while allowing escape to avoid tension pneumothorax. Applying a sterile occlusive dressing taped on three sides is the best action, as it creates a one-way valve for air exit. High-Fowler position (B) does not address the open wound, clamping (C) is unnecessary since the tube is dislodged, and obtaining a chest x-ray (D) delays urgent intervention. This prevents atmospheric air from entering the pleural space, which could collapse the lung. The principle is based on maintaining negative intrapleural pressure. A transferable strategy is to always have emergency supplies like occlusive dressings ready for chest tube dislodgement.

Question 7

A 49-year-old client with a chest tube for postoperative pneumothorax has continuous bubbling in the water-seal chamber. VS: HR 104, RR 22, BP 134/76, SpO2 93% on 3 L/min nasal cannula; drainage is 20 mL serosanguineous in 1 hr. What is the nurse's PRIORITY action if an air leak is suspected?

  1. Check for loose connections and ensure the dressing is occlusive and intact (correct answer)
  2. Document the finding as expected for the first 24 hr after surgery
  3. Empty the collection chamber to reduce bubbling in the water seal
  4. Obtain an order for prophylactic antibiotics due to the bubbling
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key assessment findings include continuous bubbling suggesting a possible external air leak. Checking for loose connections and ensuring the dressing is occlusive is the best action, as it locates and fixes system breaches. Documenting as expected (B) ignores potential issues, emptying the chamber (C) is incorrect, and antibiotics (D) are unrelated. Continuous bubbling post-op may indicate unresolved leaks. The principle is maintaining a sealed system. A transferable strategy is to systematically trace the tubing for defects when bubbling is continuous.

Question 8

A 69-year-old client with a chest tube for pneumothorax suddenly has the tube pulled out during transfer. VS: HR 120, RR 32, BP 150/88, SpO2 84% on 6 L/min nasal cannula; the insertion site is open and air is heard. What is the nurse's IMMEDIATE action?

  1. Cover the site with sterile petrolatum gauze and tape on three sides (correct answer)
  2. Apply firm pressure with dry gauze and tape on all four sides
  3. Insert the chest tube back into the tract to reestablish drainage
  4. Place the client supine and obtain a full respiratory assessment
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key interventions include covering the open site to prevent air entry while allowing exit during exhalation. Covering with sterile petrolatum gauze taped on three sides is the best action, as it acts as a flutter valve. Firm pressure on all sides (B) traps air, reinserting (C) is unsafe, and supine position (D) does not address the wound. This prevents tension pneumothorax. The principle is one-way air flow. A transferable strategy is to use vented dressings for dislodgement emergencies.

Question 9

A 52-year-old client with a chest tube for hemothorax has decreasing drainage and increasing dyspnea. VS: HR 120, RR 30, BP 104/64, SpO2 88% on 8 L/min simple mask; the tubing has a visible dependent loop with dark fluid. Which assessment finding indicates a complication with the chest tube?

  1. Dependent loop in tubing with possible obstruction and worsening oxygenation (correct answer)
  2. No bubbling in the water-seal chamber while the client is not coughing
  3. Drainage system maintained upright at bedside
  4. Serosanguineous drainage changing to straw-colored over time
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key assessment findings include dependent loops causing obstruction, leading to backed-up fluid and dyspnea. A dependent loop with obstruction and worsening oxygenation best indicates a complication, as it prevents proper drainage. No bubbling at rest (B) is normal, upright system (C) is correct, and changing drainage color (D) is expected. Obstructions can cause tension hemothorax. The rationale is that gravity-dependent positioning ensures flow. A transferable strategy is to coil excess tubing without loops to maintain patency.

Question 10

A 62-year-old client with a chest tube for hemothorax has output of 120 mL/hr of dark red drainage for the past 3 hr. VS: HR 118, RR 24, BP 90/54, SpO2 92% on 6 L/min nasal cannula. Which assessment finding indicates a complication with the chest tube?

  1. Ongoing bloody output with hypotension and tachycardia suggesting continued bleeding (correct answer)
  2. Tidaling in the water-seal chamber that decreases when the client coughs
  3. Small amount of serosanguineous drainage on the dressing edges
  4. No continuous bubbling in the water-seal chamber at rest
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key assessment findings include persistent high-volume bloody drainage with shock signs indicating hemorrhage. Ongoing bloody output with hypotension and tachycardia best indicates a complication, as it suggests uncontrolled bleeding. Tidaling decreasing with cough (B) may be normal, small dressing drainage (C) is typical, and no bubbling at rest (D) is expected. Prolonged excessive drainage requires intervention. The rationale is trending output against vital signs. A transferable strategy is to notify for output over 100 mL/hour persisting beyond initial hours.

Question 11

A 74-year-old client has a chest tube for postoperative pneumothorax. VS: T 38.2°C, HR 98, RR 20, BP 122/68, SpO2 95% on 2 L/min nasal cannula; the dressing is saturated and the insertion site is warm and red. Which intervention should the nurse implement to prevent infection?

  1. Reinforce the saturated dressing with additional gauze without removing it
  2. Change the dressing using sterile technique and assess the site for drainage and odor (correct answer)
  3. Clean the site with alcohol wipes and leave it open to air to dry
  4. Delegate dressing change to assistive personnel because it is a routine task
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key interventions for infection prevention include assessing and changing saturated dressings to reduce bacterial growth. Changing the dressing using sterile technique and assessing for drainage and odor is the best intervention, as it allows direct evaluation. Reinforcing without removal (A) may trap infection, cleaning with alcohol (C) is not sterile, and delegating (D) is inappropriate. Saturated dressings increase infection risk in warm environments. The rationale is aseptic technique at insertion sites. A transferable strategy is to change dressings when soiled and culture if purulent.

Question 12

A 58-year-old client is 8 hr post-thoracic surgery with a chest tube for pneumothorax. Assessment: VS HR 96, RR 20, BP 132/78, SpO2 95% on 2 L NC; water-seal chamber shows intermittent bubbling with coughing and tidaling present; drainage is serosanguineous 60 mL over the last 4 hr. Which assessment finding indicates a complication with the chest tube?

  1. Intermittent bubbling in the water-seal chamber during coughing, with the bubbling ceasing once the cough subsides
  2. Tidaling in the water-seal chamber with spontaneous respirations, with the fluid level rising on inspiration and falling on expiration
  3. Sudden cessation of tidaling with increased dyspnea and diminished breath sounds on the affected side (correct answer)
  4. Serosanguineous drainage totaling 60 mL over 4 hr, an average of 15 mL per hour
Explanation: Sudden cessation of tidaling with increased dyspnea and diminished breath sounds on the affected side is the danger sign. This combination suggests the chest tube may be blocked, displaced, or failing to manage reaccumulating air, so the nurse should intervene immediately. The other findings are not complications. Intermittent bubbling that occurs only during coughing is expected because coughing transiently raises intrathoracic pressure, especially if the bubbling stops when the cough subsides. Tidaling that rises with inspiration and falls with expiration during spontaneous respirations reflects normal pressure transmission through the water-seal system. Serosanguineous drainage of 60 mL over 4 hours is a low output of about 15 mL per hour, which is within the usual range after thoracic surgery. The warning is not the movement of the chest tube alone but a change in that movement together with worsening dyspnea and decreased breath sounds.

Question 13

A 60-year-old client is 4 hr post-thoracic surgery with a chest tube for pneumothorax. VS: HR 112, RR 26, BP 140/82, SpO2 89% on 5 L/min nasal cannula; continuous bubbling is present in the water-seal chamber. What is the nurse's PRIORITY action if an air leak is suspected?

  1. Assess the client for respiratory distress and ensure the system is intact and below chest level (correct answer)
  2. Turn off the suction for 30 minutes and observe whether the bubbling in the water-seal chamber stops or continues
  3. Request an order to remove the chest tube because continuous bubbling in the water-seal chamber indicates the system is malfunctioning
  4. Obtain a sputum culture to rule out pneumonia as the cause of the low oxygen saturation and tachypnea
Explanation: The priority when a chest tube has continuous bubbling and the client is hypoxemic is to evaluate the client first and verify that the system is intact, including that the drainage unit is below the chest. An air leak can come from the client or the system; assessing for respiratory distress and positioning is immediate. Turning off suction before assessing the client is troubleshooting the equipment without first addressing client safety; it does not tell you if the leak is from the client, and suction should not be turned off without knowing the clinical picture. Requesting removal of the chest tube is premature because a suspected air leak is managed by checking connections and the system, not by pulling the tube. Obtaining a sputum culture is unrelated to an air leak and would not correct the hypoxemia; pneumonia is not indicated by continuous bubbling. Therefore, the correct action is to assess for respiratory distress and ensure the system is intact and below chest level.

Question 14

A 66-year-old client with a chest tube for hemothorax reports increased chest pressure. VS: HR 124, RR 30, BP 86/50, SpO2 88% on 10 L/min nonrebreather; drainage has abruptly stopped over the last hour, and the tubing appears kinked under the bedrail. What is the nurse's PRIORITY action?

  1. Straighten the tubing to remove the kink and reassess respiratory status and drainage (correct answer)
  2. Clamp the chest tube to prevent additional pressure changes and then reassess breath sounds
  3. Measure the chest tube insertion length and mark it for trending to detect dislodgement
  4. Request an order for pain medication before manipulating the tubing to ease patient discomfort
Explanation: The priority is to correct the mechanical obstruction. Abrupt cessation of drainage with a visible kink and signs of respiratory distress indicates the chest tube is occluded. Straightening the tubing restores patency, allowing drainage and reducing pressure, and reassessment confirms improvement. Clamping the tube is dangerous because it traps air or fluid and can cause tension pneumothorax. Measuring insertion length addresses possible dislodgement, but the immediate problem is the kink, not migration. Requesting pain medication delays the necessary intervention and does not relieve the blockage. The nurse must first remove the kink and then reassess.

Question 15

A 72-year-old client has a chest tube for a postoperative pneumothorax. VS: T 38.4°C, HR 104, RR 20, BP 128/72, SpO2 94% on 2 L/min nasal cannula; the insertion site is erythematous with purulent drainage and tenderness. Which intervention should the nurse implement to prevent infection?

  1. Change the chest tube dressing using sterile technique per facility policy (correct answer)
  2. Milk the chest tube every 2 hr to prevent fluid from backing up
  3. Clamp the chest tube during client repositioning to prevent contamination
  4. Delegate cleansing of the insertion site to assistive personnel each shift
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key interventions for infection prevention include maintaining sterile technique during dressing changes and monitoring for signs like erythema and purulent drainage. Changing the chest tube dressing using sterile technique per facility policy is the best intervention, as it allows assessment and reduces infection risk. Milking the tube (B) is not indicated for infection, clamping during repositioning (C) risks tension pneumothorax, and delegating site cleansing (D) to assistive personnel is inappropriate for potentially infected sites. Sterile dressing changes remove contaminants and promote healing. The rationale is that chest tube sites are portals for infection, especially in immunocompromised older adults. A transferable strategy is to perform dressing changes with strict asepsis and notify the provider of any infection signs immediately.

Question 16

A 71-year-old client has a chest tube for postoperative pneumothorax. VS: T 38.6°C, HR 106, RR 22, BP 118/66, SpO2 94% on 2 L/min nasal cannula; the insertion site has increasing redness and foul-smelling drainage. Which intervention should the nurse implement to prevent infection?

  1. Perform hand hygiene and change the dressing using sterile technique, then notify the provider of findings (correct answer)
  2. Apply topical antibiotic ointment to the insertion site without removing the dressing
  3. Irrigate the chest tube tract with sterile saline to remove drainage
  4. Place a warm compress over the dressing to improve circulation and healing
Explanation: This question tests chest tube monitoring and troubleshooting skills. Key interventions for infection prevention include sterile dressing changes and provider notification for signs like redness and drainage. Performing hand hygiene and changing the dressing sterilely, then notifying the provider, is the best intervention, as it addresses infection promptly. Topical ointment without change (B) is insufficient, irrigation (C) is not standard, and warm compress (D) may worsen infection. Early intervention prevents sepsis. The rationale is asepsis at invasive sites. A transferable strategy is to monitor sites daily and culture suspicious drainage.

Question 17

A 39-year-old client has a chest tube for pneumothorax after rib fractures. During ambulation, the chest tube disconnects from the drainage system; the client becomes anxious with RR 30 and SpO2 86% on 4 L NC. What is the nurse's IMMEDIATE action?

  1. Apply an occlusive dressing taped on all four sides over the insertion site
  2. Place the end of the chest tube in sterile water to create a water seal and then reestablish the drainage system (correct answer)
  3. Clamp the chest tube and notify the provider
  4. Obtain a STAT portable chest x-ray before intervening
Explanation: This question tests chest tube monitoring and troubleshooting skills, specifically managing accidental disconnection of the chest tube from the drainage system. The key situation is a disconnected chest tube during ambulation with immediate respiratory distress (RR 30, SpO2 86%), requiring immediate action to prevent air from entering the pleural space. Placing the end of the chest tube in sterile water to create a water seal and then reestablishing the drainage system (B) is the correct immediate action because it prevents air from entering the pleural space while maintaining drainage capability. Applying an occlusive dressing taped on all four sides (A) would be appropriate for a dislodged tube but not for a disconnection, clamping the chest tube (C) could cause tension pneumothorax if air is still leaking from the lung, and obtaining a chest x-ray (D) delays critical intervention. The underlying principle is that maintaining a water seal is essential to prevent atmospheric air from entering the pleural space through the chest tube, which could worsen the pneumothorax. When chest tube disconnection occurs, immediately create a temporary water seal to prevent complications while working to reestablish the closed drainage system.

Question 18

A 67-year-old client has a left chest tube for hemothorax after a motor vehicle crash. Current assessment: VS HR 122, RR 28, BP 88/54, SpO2 90% on 10 L nonrebreather; chest tube drainage is bright red and has increased from 150 mL in the last hour to 250 mL in the last 30 min. Which assessment finding indicates a complication with the chest tube?

  1. Bright red drainage of 250 mL in 30 min with hypotension and tachycardia (correct answer)
  2. Serosanguineous drainage of 40 mL/hr during the first postoperative day
  3. Tidaling in the water-seal chamber with spontaneous respirations
  4. No bubbling in the suction-control chamber when suction is turned off
Explanation: This question tests chest tube monitoring and troubleshooting skills, specifically recognizing signs of hemorrhage in a hemothorax patient. The key assessment findings include bright red drainage of 250 mL in 30 minutes combined with hypotension (BP 88/54) and tachycardia (HR 122), which clearly indicate active hemorrhage requiring immediate intervention. Bright red drainage of 250 mL in 30 minutes with hypotension and tachycardia (A) is the correct answer because this represents excessive blood loss (>100 mL/hr) with hemodynamic instability. Serosanguineous drainage of 40 mL/hr (B) is within normal limits for the first postoperative day, tidaling in the water-seal chamber (C) is an expected finding indicating patent chest tube function, and no bubbling in the suction-control chamber when suction is off (D) is also normal. The clinical principle is that chest tube output >100 mL/hr of bright red blood, especially with vital sign changes, indicates active hemorrhage requiring immediate notification of the provider and preparation for potential surgical intervention. When monitoring chest tubes for hemothorax, always correlate drainage amount, color, and rate with vital signs to identify life-threatening hemorrhage.

Question 19

A 46-year-old client has a chest tube for pneumothorax following thoracic surgery. The nurse finds the chest tube has partially pulled out and the dressing is saturated; VS: HR 118, RR 26, BP 140/84, SpO2 88% on 6 L NC. What is the nurse's IMMEDIATE action?

  1. Reinsert the chest tube to the previous depth and secure it with new tape before calling the provider
  2. Cover the site with a sterile occlusive dressing taped on three sides and call for help (correct answer)
  3. Clamp the chest tube near the insertion site with padded forceps to prevent air entry while awaiting assessment
  4. Ask the UAP to obtain a new drainage system and set up replacement supplies while the nurse documents the event
Explanation: The partially pulled chest tube with a saturated dressing and SpO2 88% indicates an open pneumothorax and risk of tension pneumothorax. The immediate priority is to cover the site with a sterile occlusive dressing taped on three sides and call for help; this creates a one-way valve that lets air escape while preventing air from entering, stabilizing the client while definitive chest tube replacement is arranged. Reinserting the chest tube to the previous depth and taping it is outside nursing scope and can push a contaminated tube deeper, worsening the injury. Clamping the tube with padded forceps does not seal the chest wall defect and can trap air, converting a simple leak into tension pneumothorax. Asking the UAP to obtain a new drainage system and set up supplies while the nurse documents delays the life-saving occlusive dressing and delegates an urgent clinical judgment task. The three-sided occlusive dressing is the only option that directly addresses the immediate threat.

Question 20

A 54-year-old client is 6 hr post-thoracic surgery with a right chest tube for pneumothorax; VS: T 37.1 C (98.8 F), HR 104, RR 22, BP 128/76, SpO2 92% on 2 L NC. The nurse notes continuous bubbling in the water-seal chamber and chest tube drainage is serosanguineous 40 mL/hr. What is the nurse's PRIORITY action if an air leak is suspected?

  1. Increase wall suction to -40 cm H2O to stop the bubbling
  2. Systematically clamp the chest tube briefly starting closest to the client to localize the leak, while monitoring respiratory status (correct answer)
  3. Document the finding as expected for the first 24 hr after surgery
  4. Delegate to the UAP to check all chest tube connections for loose tape
Explanation: This question tests chest tube monitoring and troubleshooting skills, specifically identifying and managing air leaks in the drainage system. The key assessment finding is continuous bubbling in the water-seal chamber 6 hours post-surgery, which indicates an air leak that needs to be localized. Systematically clamping the chest tube briefly starting closest to the client while monitoring respiratory status (B) is the correct approach because it helps identify whether the leak is in the chest cavity or the drainage system without compromising patient safety. Increasing wall suction (A) would not stop bubbling from an air leak and could worsen the situation, documenting as expected (C) is incorrect because continuous bubbling is not normal at any time post-surgery, and delegating assessment to UAP (D) is inappropriate as this requires nursing judgment and immediate intervention. The underlying principle is that air leaks must be promptly identified and localized to prevent complications like tension pneumothorax while maintaining patient safety during the assessment process. When troubleshooting chest tube problems, always use a systematic approach that prioritizes patient safety while identifying the source of the problem.