# A nurse cares for a client 12 hours after thoracotomy with a chest tube connected to a wet-suction, water-seal drainage system. Which findings should the nurse report to the provider immediately? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=366310&lang=en > language: en > subject: Complications of Procedures > category: ROR ## Question A nurse cares for a client 12 hours after thoracotomy with a chest tube connected to a wet-suction, water-seal drainage system. Which findings should the nurse report to the provider immediately? Select all that apply. 1 Continuous bubbling in the water-seal chamber 2 Drainage of 250 mL of bright red blood in the past hour 3 Sudden absence of bubbling and stopped tidaling with new shortness of breath 4 Drainage of 60 mL of serosanguineous fluid in the past hour 5 Gentle tidaling synchronized with respirations in the water-seal chamber ## Explanation Continuous bubbling in the water-seal chamber suggests an air leak in the system or a persistent pleural air leak — investigate immediately. Sudden absence of bubbling and stopped tidaling with new dyspnea may indicate tube obstruction or re-expansion. Drainage of 250 mL of bright red blood in 1 hour exceeds typical post-thoracotomy expectations and may indicate intrathoracic hemorrhage. 60 mL serosanguineous over 1 hour and gentle tidaling with respirations are normal early postoperative findings. ## In-depth explanation Clinical Judgment Chest tube key signs: tidaling = patent system; intermittent bubbling with cough = expected during initial phase; continuous bubbling = air leak; absent tidaling and bubbling = obstruction or full lung re-expansion. Sudden brisk bright red drainage >100 mL/hour or >200 mL/hour for several hours = surgical hemorrhage. Memory Tip Tidaling good; Continuous bubble bad; Absent tidaling + dyspnea = check; >100 mL/h bright red = surgical KR vs U STS (Society of Thoracic Surgeons) and Korean thoracic surgery guidelines align: dressing occlusive at insertion, system below chest level, never clamp tubing routinely, document drainage hourly and tidaling/bubbling each shift. Both jurisdictions endorse digital chest drains where available. ## Clinical scenario Clinical Practice Guide Chest tube nursing essentials: - Drainage system below chest level; never raise above the chest - Tidaling: water rises with inspiration, falls with expiration in spontaneously breathing client (opposite if mechanically ventilated). Confirms patent system. - Bubbling: intermittent with cough or activity is normal early; continuous = air leak from system or lung - Drainage thresholds: report >100 mL/hour bright red or sudden change - Air leak workflow: check connections, then briefly clamp near insertion site to localize (per protocol only); do not clamp routinely - Accidental dislodgement: place a 4x4 dressing taped on three sides over the insertion (Vaseline gauze if available); never apply a fully occlusive dressing - Disconnection: submerge the chest tube end in sterile water 2-4 cm and notify provider Caution Tension pneumothorax can develop rapidly: absent breath sounds, tracheal deviation, hypotension, JVD, severe distress. Emergency needle decompression second intercostal midclavicular line, then chest tube replacement. ## Key concepts - **Tidaling** — Fluctuation of fluid level in the water-seal chamber that rises with inspiration and falls with expiration in a spontaneously breathing client (opposite in mechanical ventilation). Indicates a patent system and intact pleural seal. Absent tidaling = obstruction, kink, or full lung re-expansion. - **Air leak (continuous bubbling)** — Continuous bubbling in the water-seal chamber suggests air entering the pleural space (lung air leak) or a system air leak. Localize by briefly clamping the tube near the insertion site per protocol; if bubbling stops, source is the lung. Notify the provider. - **Tension pneumothorax** — Life-threatening accumulation of pleural air with one-way valve effect, increasing pressure, mediastinal shift, and hemodynamic collapse. Signs: absent breath sounds, tracheal deviation away from the affected side, hypotension, JVD, severe distress. Emergency: needle decompression at the second intercostal space midclavicular line, then chest tube placement. ## Related questions - [A nurse is caring for a 64-year-old client 2 hours after a diagnostic cardiac catheterizat…](https://mymerci.kr/pages/nclex_q.php?qn_id=368186&lang=en) - [A patient on mechanical ventilation has bilateral infiltrates on chest x-ray, no signs of …](https://mymerci.kr/pages/nclex_q.php?qn_id=372717&lang=en) - [A 38-week newborn is delivered limp, apneic, and cyanotic. 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