22. A nurse should anticipate that the chest tube for a client recovering from a pneumothorax will be removed when:
22. A nurse should anticipate that the chest tube for a client recovering from a pneumothorax will be removed when:
. Chest drainage decreases to 50 mL in 24 hours.
. Chest x-ray shows atelectasis has resolved.
. Water-seal chamber no longer fluctuates with breathing.
. Breath sounds are present bilaterally in apical lobes.
Test-Taking Tip
Remember the water seal allows air and fluid to escape from the lung. As the client breathes in, the fluid level rises. If that action has stopped, the system may no longer be needed.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Therapeutic Procedures
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Answer 1 is incorrect because there may have been little drainage if the chest drainage system was removing air, not blood. There should be minimal drainage before removal also. Answer 2 is incorrect because a pneumothorax is a collapse of the lung, partial or complete, not a collapse of alveoli. Answer 3 is correct because the cessation of fluctuation in the water-seal chamber when the chest drainage system is no longer attached to suction is an indication of re-expansion. A chest x-ray would also be indicated. Answer 4 is incorrect because presence of breath sounds would need to be in all lobes, and particularly in the area of lung collapse.