Question

19. A client is 3 hours postoperative following a right upper lobectomy. The collection chamber of the closed pleural drainage system contains 400 ml of bloody drainage. The client's vital signs are blood pressure 100/50 mmHg, heart rate of 100 beats per minute, and respiratory rate 26 breaths per minute. There is intermittent bubbling in the water seal chamber. One hour following the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant and the client appears dyspneic. The nurse should first check:

a) lung sounds
b) vital signs
c) the chest tube connections
d) the amount of drainage

Answer 1

The first action for the nurse should be to check the lung sounds of the client who is dyspneic with constant bubbling in the water seal chamber postoperatively, as this can give immediate information about the client's respiratory status and help identify a potential pneumothorax.

Step-by-step explanation:

The client is experiencing a constant bubbling in the water seal chamber of their closed pleural drainage system postoperatively, which may indicate an air leak in the system. This could be a sign of worsening condition, such as a pneumothorax. Given the client's appearance of dyspnea (difficulty breathing), the nurse's first action should be to check the lung sounds. This initial step helps to assess for the presence of equal breath sounds, any new or exacerbating respiratory issues, and the effectiveness of the lobectomy. If lung sounds are diminished or absent on the surgical side, it could be a sign that air has accumulated in the pleural space (pneumothorax). The nurse should also check the chest tube connections to ensure they are secure and not contributing to an air leak. It is crucial to monitor the vital signs and the amount of drainage to assess overall stability, but auscultating the lung sounds is a key step in this scenario because it provides direct information about the respiratory status of the client post-surgery.