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Registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?

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Answer:

The correct Optons were not given in the question. Correct options should be:

1. Call the health care provider (HCP).

2. Place the tube in a bottle of sterile water.

3. Replace the chest tube system.

4. Place a sterile dressing over the disconnection site.

The answer should be;

2. Place the tube in a bottle of sterile water.

Explanation:

Presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration.Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has re-expanded.

Now, If the chest drainage system is disconnected, the end of the tube is being placed in a bottle of sterile water positioned below the level of the chest. The HCP may need to be notified, but this is not the initial action. Options 1, 3, and 4 are incorrect.

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