Question

A client who has undergone surgery is three days post-op and continues to have chest tubes on the left side to water seal. The client is beginning to ambulate with family. The nurse teaches the client and family which priority intervention:

a) Monitor for any signs of bleeding around the chest tube site.

b) Limit ambulation to prevent dislodging the chest tubes.

c) Encourage deep breathing and coughing exercises.

d) Disconnect the chest tubes temporarily during ambulation.

Answer 1

The nurse should instruct the patient and family to prioritize deep breathing and coughing exercises to promote lung expansion and prevent complications post-op. Monitoring for bleeding is important but secondary to respiratory exercises, while limiting ambulation or disconnecting chest tubes is not advised.

Step-by-step explanation:

The priority intervention the nurse should teach the client and family after surgery, when the client has chest tubes connected to a water seal, and is beginning to ambulate, is c) Encourage deep breathing and coughing exercises. This is crucial for promoting lung expansion, preventing atelectasis (partial lung collapse), and facilitating the removal of secretions. These exercises help in maintaining adequate gas exchange, which is vital for the recovery of patients post-operation, especially considering that muscles necessary for respiration might still be recovering from the effects of general anesthesia.

Monitoring for signs of bleeding around the chest tube site is important, but not the primary intervention related to ambulation. Limiting ambulation could be counterproductive to recovery and is not recommended unless specified by a healthcare provider, and disconnecting the chest tubes would be dangerous and is not within the scope of practice for a patient or their family.