Hesi RN Medsurg Proctored Exam
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Hesi RN Medsurg Proctored Exam
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Question: 1 of 48Hesi RN Medsurg Proctored Exam
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Explanation
B. Tidaling is an expected finding in a functioning chest drainage system and indicates proper drainage of air or fluid from the pleural space. Continuously monitoring the drainage system allows the nurse to assess the volume, color, and consistency of drainage. A. Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube. C. Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider. D. While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.
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