2. If fluctuation (tidaling) in the water-seal compartment of a closed chest drainage system has stopped, a nurse should:
2. If fluctuation (tidaling) in the water-seal compartment of a closed chest drainage system has stopped, a nurse should:
. Increase wall suction above 20 cm H2O pressure.
. Raise the apparatus above the chest to move the fluid.
. Ask the client to cough and deep breathe.
. Vigorously strip the tube to dislodge the clot.
Test-Taking Tip
Remember that the water seal fluctuates with changes in the intrathoracic pressure from breathing.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
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Answer 1 is incorrect because the level of wall suction does not affect the water seal. This pressure enhances drainage. Answer 2 is incorrect because closed chest drainage should always remain below the level of the heart. Answer 3 is correct because this will change the intrapleural pressure and reestablish suctioning. Answer 4 is incorrect because stripping a chest tube may cause trauma to the lung.