During the first 36 hours after the insertion of chest tubes, while assessing the function of a chest drainage system, the nurse identifies that the water in the underwater seal tube is not moving. What INITIALaction should the nurse take?

1. A

   Record patient’s vital signs immediately

2. B

   Check the tube to ensure that it is not kinked

3. C

   Turn the patient to the unaffected side

4. D

   Inform the physician

Appeared in: BHU NO-2019

Explanation

• The absence of water movement (tidaling) in the water-seal chamber indicates either that the lung has fully re-expanded or that the system is obstructed.
• In the initial 36-hour period after insertion, an obstruction is a more probable cause than full lung re-expansion.
• The nurse's first action should be to perform the simplest and most immediate troubleshooting step.
• Checking the tubing for kinks is a quick, non-invasive assessment to rule out a common cause of obstruction.

Why Other Options Were Wrong

• Option A: While assessing vital signs is a crucial part of patient monitoring, it does not address the immediate problem of a potential equipment malfunction. The primary issue is the lack of tidaling, which points to a system problem.
• Option C: Repositioning the patient might help if the drainage holes inside the chest are occluded by lung tissue, but it is not the initial action. An external, visible obstruction like a kink should be ruled out first.
• Option D: Informing the physician is an act of escalation. The nurse should first perform a basic assessment and simple troubleshooting steps within their scope of practice.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Troubleshooting of a chest drainage system in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• A non-functioning chest tube can lead to a tension pneumothorax, a life-threatening condition where air accumulates in the pleural space and cannot escape, causing the lung to collapse and shifting the mediastinum.
• Nurses must be able to systematically troubleshoot chest drainage systems to ensure patient safety and prevent complications.
• What if? If the patient with no tidaling also developed sudden shortness of breath, tracheal deviation away from the affected side, and hypotension, the nurse should suspect a tension pneumothorax and call for immediate medical assistance (e.g., a rapid response team) and notify the physician urgently, as this is a medical emergency.

How to Approach the Question

• First, identify the key clinical finding in the question stem: the water in the underwater seal tube is not moving (no tidaling).
• Next, recall the two primary reasons for absent tidaling: 1) the lung has re-expanded (a positive outcome), or 2) the system is obstructed (a negative and urgent problem).
• Consider the context provided: 'the first 36 hours'. This makes complete lung re-expansion less likely and increases the suspicion of an obstruction.
• Evaluate the options based on nursing priorities. The initial action should be the simplest, fastest, and most direct step to address the most likely problem.
• Checking for a kink directly addresses the high probability of an obstruction. The other options are either secondary assessments (vitals), later interventions (repositioning), or escalation (informing the physician).

Concept Tested & Keywords

• Concept Tested: Troubleshooting of a chest drainage system.
• Stem keywords: chest tubes, chest drainage system, underwater seal tube, not moving, first 36 hours
• Lead-in keywords: INITIAL action
• Clinical cues: The timeframe of 'first 36 hours' is a key cue, as it makes an obstruction more likely than full lung re-expansion.

Question ID

QT9H2xjn2rXpDOvwoyG_Z3

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 36-38, 32-34

E6 Nursing Fundamentals Taylor p. 734-736