Chest Tube And Drainage Device Care
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NCLEX-PN › Chest Tube And Drainage Device Care
A 56-year-old client is 12 hours post-thoracotomy with a chest tube to a water-seal drainage device. Current status: temperature 98.9°F (37.2°C), heart rate 102/min, blood pressure 118/72 mm Hg, respiratory rate 22/min, oxygen saturation 92% on 2 L/min nasal cannula; drainage has suddenly increased from 30 mL/hr to 220 mL in the last hour and is bright red. Which finding should be REPORTED immediately to the RN?
Temperature is 98.9°F (37.2°C) and blood pressure is 118/72 mm Hg
Oxygen saturation is 92% on 2 L/min nasal cannula
Heart rate is 102/min and respiratory rate is 22/min
Drainage has increased to 220 mL in the last hour and is bright red
Explanation
This question tests clinical judgment in recognizing hemorrhage as a post-thoracotomy complication requiring immediate intervention. The priority concern is active bleeding indicated by the sudden increase to 220 mL/hr of bright red drainage, which suggests arterial bleeding or major vessel injury. Reporting the increased bright red drainage (B) is correct because this volume and appearance indicate hemorrhage requiring immediate medical evaluation and possible return to surgery. Oxygen saturation of 92% (A) is slightly low but not immediately life-threatening, elevated vital signs (C) are expected post-operatively and with mild hypoxemia, and the temperature and blood pressure (D) are within normal limits. The decision-making principle is recognizing drainage patterns that indicate hemorrhage versus expected post-operative drainage. When monitoring post-thoracotomy drainage, immediately report outputs exceeding 100 mL/hr after the first 2 hours, sudden increases in drainage, or color changes to bright red.
A 74-year-old client with heart failure is admitted to an acute care unit for a large right pleural effusion and has a new right chest tube connected to a water-seal drainage device. Current status: heart rate 98/min, blood pressure 138/76 mm Hg, respiratory rate 22/min, oxygen saturation 93% on 3 L/min nasal cannula; breath sounds are diminished at the right base; 900 mL of straw-colored drainage has collected in the first hour. Which finding should be REPORTED immediately to the RN?
Breath sounds are diminished at the right base but present in the upper lobe
900 mL of drainage has collected during the first hour after insertion
The drainage is straw-colored and the collection chamber is kept below chest level
Continuous gentle bubbling is present in the suction-control chamber when suction is on
Explanation
This question tests clinical judgment in recognizing excessive chest tube drainage requiring immediate intervention. The priority concern is hemorrhage or rapid fluid loss, as 900 mL in the first hour far exceeds the normal expected drainage of 100-300 mL/hr initially. Reporting this finding immediately (C) is correct because excessive drainage can lead to hypovolemic shock and requires urgent medical evaluation and possible surgical intervention. Gentle bubbling in the suction chamber (A) is normal when suction is applied, straw-colored drainage below chest level (B) indicates proper positioning and expected drainage characteristics, and diminished breath sounds at the base (D) are expected with pleural effusion. The decision-making principle is recognizing abnormal drainage volumes that indicate potential hemorrhage or rapid fluid shifts. When monitoring chest tube output, immediately report drainage exceeding 100 mL/hr after the first 2 hours or any sudden increase in bloody drainage.