# A patient is one day post-thoracotomy with a chest tube connected to a closed-chest drainage system to wall suction. Which assessments and interventions should the nurse include in routine shift care? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372755&lang=en > language: en > subject: Complications of Procedures > category: ROR ## Question A patient is one day post-thoracotomy with a chest tube connected to a closed-chest drainage system to wall suction. Which assessments and interventions should the nurse include in routine shift care? Select all that apply. 1 Routinely strip or milk the chest tube every 2 to 4 hours to maintain patency and prevent clot formation in the tubing. 2 Assess for tidaling in the water-seal chamber on inspiration and expiration; cessation of tidaling may indicate lung re-expansion or tubing obstruction. 3 Keep a clamp, sterile occlusive dressing, and bottle of sterile water at the bedside in case of accidental disconnection. 4 Inspect drainage every shift for color and amount, marking the level with date and time on the collection chamber. 5 Keep the drainage system below the level of the chest at all times and check tubing for kinks, dependent loops, and clots. ## Explanation Chest tube nursing care: (1) inspect drainage each shift for character and amount, mark the chamber with date/time and shift level — sudden increase >100 mL/hr or bright red drainage warrants immediate notification; (2) keep system below the chest, check tubing free of kinks, dependent loops, and clots — these all impede drainage and can produce a tension pneumothorax; (3) assess tidaling — fluctuation of water in the water-seal chamber with respiration confirms patency; cessation can mean lung re-expansion (good) or obstruction (bad), distinguished by clinical assessment; (5) keep clamp, sterile occlusive dressing, and bottle of sterile water at bedside — clamp is for chamber change only, occlusive dressing for tube dislodgement at chest wall, sterile water for system disconnection (immerse end of tubing in water to maintain water seal). Choice 1 is incorrect — routine stripping or milking is no longer recommended; it generates dangerously high negative pressure that can damage lung tissue and is reserved for documented obstruction by clot per institutional policy. ## In-depth explanation A closed-chest drainage system has three chambers — collection (drainage from the patient), water seal (a one-way valve that prevents air re-entry and shows tidaling and air leak), and suction control (regulating negative pressure via a water column or dial) — and must always sit below the patient's chest. Routine clamping is forbidden because it risks tension pneumothorax; only brief clamping is allowed for system change or per provider order. Tidaling describes water in the water-seal chamber rising with inspiration (negative intrathoracic pressure) and falling with expiration in a spontaneously breathing patient (reversed with positive-pressure ventilation); continuous bubbling in the water seal indicates an air leak (check connections, then patient), and cessation of tidaling means lung re-expansion (no longer needed) or obstruction (still needed, problem). Emergency bedside supplies include a padded clamp (for system change only, never routine), a sterile occlusive dressing (for tube dislodgement at the chest wall, taped on three sides as a tension-pneumothorax precaution), and sterile water (for accidental system disconnection — immerse the patient end of the tubing in the water to maintain the water seal until the system is replaced). ## Clinical scenario A patient is **1 day post-thoracotomy** with a **chest tube connected to a closed-chest drainage system to wall suction**. The nurse plans routine shift care. ## Key concepts - **Closed-Chest Drainage System Compartments** — Three chambers: collection (drainage from patient), water seal (one-way valve, prevents air re-entry, shows tidaling and air leak), suction control (regulates negative pressure via water column or dial). Always below the chest. Never clamp routinely (risk of tension pneumothorax) — only briefly for system change or per provider order. - **Tidaling and Air Leak** — Tidaling: water in the water-seal chamber rises with inspiration (negative intrathoracic pressure) and falls with expiration in a spontaneously breathing patient (reverse with positive-pressure ventilation). Continuous bubbling in the water seal indicates an air leak — check connections, then patient. Cessation of tidaling: lung re-expansion (no longer needed) or obstruction (still needed, problem). - **Emergency Bedside Supplies** — Padded clamp (for system change only — never routine), sterile occlusive dressing (for tube dislodgement at the chest wall, taped on three sides for tension pneumothorax precaution), sterile water (for accidental system disconnection — immerse the patient end of the tubing in the water to maintain water seal until system is replaced). ## Related questions - [A nurse cares for a client 12 hours after thoracotomy with a chest tube connected to a wet…](https://mymerci.kr/pages/nclex_q.php?qn_id=366310&lang=en) - [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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