The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply.

Question

Quizplus · Accepted Answer

When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds (Option A) helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe (Option C) and repositioning the client (Option E). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. (Option B) A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H₂O is not indicated. (Option D) Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space. Educational objective: The nurse should assess breath sounds, encourage coughing and deep breathing, and reposition the client who has a decrease in chest tube drainage.

The Nurse Is Caring for a Client with a Chest