# A 64-year-old client is on postoperative day 1 after a right upper lobectomy, with a right chest tube connected to a drainage system at -20 cm H2O suction. Drainage over the past 8 hours was 120 mL of serosanguineous fluid. The client suddenly becomes short of breath and anxious. The nurse finds the chest tube disconnected from the drainage tubing, with air audibly moving at the open end of the tube. Oxygen saturation is 88% on 2 L/min by nasal cannula, respiratory rate 28/min, heart rate 108/min, and blood pressure 132/80 mm Hg. Breath sounds are diminished at the right base, the trachea is midline, neck veins are flat, and the insertion-site dressing is dry and intact. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617414&lang=en > language: en > subject: Complications of Procedures > category: ROR ## Question A 64-year-old client is on postoperative day 1 after a right upper lobectomy, with a right chest tube connected to a drainage system at -20 cm H2O suction. Drainage over the past 8 hours was 120 mL of serosanguineous fluid. The client suddenly becomes short of breath and anxious. The nurse finds the chest tube disconnected from the drainage tubing, with air audibly moving at the open end of the tube. Oxygen saturation is 88% on 2 L/min by nasal cannula, respiratory rate 28/min, heart rate 108/min, and blood pressure 132/80 mm Hg. Breath sounds are diminished at the right base, the trachea is midline, neck veins are flat, and the insertion-site dressing is dry and intact. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition Select 1 Right tension pneumothorax Recurrent pneumothorax Postoperative hemothorax Pulmonary embolism Actions to take Select 2 Clamp the chest tube close to the chest wall Submerge the tube end 2 cm in sterile water Prepare for needle decompression of the chest Remove the tube and apply an occlusive dressing Attach a new sterile drainage system Parameters to monitor Select 2 Chest tube drainage per hour Oxygen saturation D-dimer level Breath sounds on the right Hemoglobin level ## Explanation Air moving at the open end of a disconnected chest tube, with sudden dyspnea and diminished right breath sounds, means air is entering the pleural space. The nurse immediately restores a one-way seal by submerging the tube end in sterile water and then attaches a new sterile drainage system. Oxygen saturation and right-sided breath sounds show re-expansion. A midline trachea with stable blood pressure excludes tension pneumothorax, and unchanged drainage argues against hemothorax. ## In-depth explanation Quick answer Recurrent pneumothorax from chest tube disconnection; submerge the tube end 2 cm in sterile water, attach a new sterile drainage system, and monitor oxygen saturation and right-sided breath sounds. Why this is correct An open chest tube lets atmospheric air enter the pleural space with each breath, collapsing lung tissue. Placing the end under 2 cm of sterile water recreates a water seal immediately, and a new sterile system restores suction and drainage. Improving saturation and returning breath sounds confirm that the lung is re-expanding. Easy analogy or mental picture Picture a snorkel open to room air on one side of the chest: every breath pulls air in. Dipping the end in water turns it back into a one-way valve. Memory hook Disconnected = dunk it (water seal), then replace the system; dislodged = cover it. NCLEX decision rule Choose the fastest action that restores the closed system, and monitor the respiratory findings that show the lung is re-expanding. Why the other choices are wrong Tension pneumothorax causes tracheal deviation, distended neck veins, and hypotension, which are absent, so needle decompression is not indicated now. Clamping is an outdated reflex that can trap air and create tension. Removing the tube and applying an occlusive dressing is the response to a tube pulled out of the chest, not a disconnection. Hemothorax would increase drainage and lower hemoglobin, and drainage has been modest. Pulmonary embolism is less likely when the dyspnea began with an obvious air leak, so a D-dimer does not track this problem. References 1MedlinePlus — Collapsed lung (pneumothorax)Air in the pleural space causes shortness of breath and lung collapse. 2MedlinePlus — Chest tube insertionChest tubes drain air and fluid from the pleural space through a sealed system. ## Clinical scenario Scenario A postoperative lobectomy client's chest tube is found disconnected with air moving at the open end; oxygen saturation is 88%, right basilar breath sounds are diminished, the trachea is midline, and blood pressure is stable. ## Key concepts - **Water seal** — A column of water that lets air leave the pleural space but prevents it from re-entering. - **Tidaling** — Rise and fall of water in the water-seal chamber with breathing, showing a patent system. - **Tension pneumothorax** — Trapped pleural air under pressure that shifts the mediastinum and impairs venous return. ## 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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