# Situation: A 22-year-old tall, thin man who smokes is admitted to the surgical ward with a right primary spontaneous pneumothorax. Six hours ago a chest tube was inserted and connected to a three-chamber drainage system with wet suction set at 20 cm H2O. On the second day, the nurse notes that tidaling in the water-seal chamber has suddenly stopped. In what order should the nurse carry out these actions? 1. Ask him to take deep breaths and cough 2. Notify the physician if tidaling does not return 3. Assess his breathing and oxygen saturation 4. Check the tubing for kinks and dependent loops

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629685  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 22-year-old tall, thin man who smokes is admitted to the surgical ward with a right primary spontaneous pneumothorax. Six hours ago a chest tube was inserted and connected to a three-chamber drainage system with wet suction set at 20 cm H2O.

On the second day, the nurse notes that tidaling in the water-seal chamber has suddenly stopped. In what order should the nurse carry out these actions?
1. Ask him to take deep breaths and cough
2. Notify the physician if tidaling does not return
3. Assess his breathing and oxygen saturation
4. Check the tubing for kinks and dependent loops

## 보기

1. 3, 1, 4, 2
2. 3, 4, 1, 2 **✔ 정답**
3. 4, 3, 1, 2
4. 4, 1, 3, 2

**정답: 2**

## 해설

The nurse assesses the client first, because sudden loss of tidaling may mean an obstruction that threatens his breathing or a lung that has re-expanded. Next the nurse checks the tubing for kinks, clots, dependent loops, or the client lying on the tube, then has him take deep breaths and cough to move fluid and clear the tube. If tidaling does not return, the nurse notifies the physician, who may confirm re-expansion by chest X-ray.

## 심화 해설

The correct order of actions
Tidaling is the normal rise and fall of fluid in the water-seal chamber with breathing. When it suddenly stops, there are two broad possibilities: the system is obstructed, or the lung has re-expanded. The nurse first assesses the client's breathing and oxygen saturation, then checks the tubing for kinks, clots, and dependent loops, then asks him to take deep breaths and cough, and finally notifies the physician if tidaling does not return. The sequence 3, 4, 1, 2 starts with the client, moves to the equipment, tries a simple maneuver, and escalates if the problem persists.

Why the client comes first
An obstructed chest tube can allow air or fluid to build up in the pleural space again, which can cause respiratory distress or, in the worst case, a tension pneumothorax. Checking the client's breathing, chest movement, and oxygen saturation tells the nurse at once whether this is an emergency. If he is in distress, the priority shifts immediately to getting help. If he is comfortable with good saturation, the change may simply reflect re-expansion of the lung, and the nurse can safely troubleshoot the system.

Troubleshooting the system
Next, the nurse traces the tubing from the chest to the drainage unit, looking for kinks, clots, dependent loops where fluid collects, and whether the client is lying on the tube. Correcting these restores drainage. Only after the tubing has been checked does the nurse ask him to take deep breaths and cough, which increases intrathoracic pressure and can move fluid or clear the tube. Asking him to cough while a kink is still present would not solve the problem.

Why the distractors are wrong
The option 3, 1, 4, 2 has the client cough before the tubing is checked. The options that start with checking the tubing place equipment before the client. Watch out! Equipment-first answers are common distractors in chest tube items. The rule is to assess the client before the machine, because the change may reflect a problem with his breathing.

| Step | Action | Purpose |
| --- | --- | --- |
| 1 | Assess breathing and oxygen saturation | Detect respiratory compromise |
| 2 | Check the tubing for kinks, clots, and dependent loops | Find and correct obstruction |
| 3 | Ask him to take deep breaths and cough | Move fluid and clear the tube |
| 4 | Notify the physician if tidaling does not return | Possible re-expansion, confirmed by chest X-ray |

Exam takeaway
When tidaling stops suddenly: assess the client, check the tubing, have him breathe deeply and cough, then notify the physician if it does not return. Key point! The physician may order a chest X-ray to confirm whether the lung has re-expanded.

## 임상 시나리오

Sudden Loss of TidalingChest tube on day 2 for spontaneous pneumothorax
First assess breathing and oxygen saturation; sudden loss of tidaling may mean obstruction or a re-expanded lung.

Then check the tubing for kinks, clots, dependent loops, or the client lying on the tube, and correct them.

Ask him to breathe deeply and cough; notify the physician if tidaling does not return, who may order a chest X-ray.

CautionDo not start with the equipment; assess the client first, and call for help at once if he is in respiratory distress.

## 핵심 개념

- **Tidaling** — The rise and fall of fluid in the water-seal chamber with breathing, showing a patent system.
- **Water-seal chamber** — The part of a chest drainage system that lets air leave the chest but not return.
- **Dependent loop** — A section of drainage tubing that hangs below the chest and collects fluid, blocking drainage.
- **Primary spontaneous pneumothorax** — Collapse of the lung without an obvious cause, often in tall, thin young men who smoke.

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