Saunders Respiratory Practice

What should a nurse do if fluctuations are observed in the water-seal chamber of a chest tube?

1. Document the findings

2. Check for kinks in the tubing

3. Increase suction pressure

4. Continue to monitor the situation

The correct answer is: Continue to monitor the situation

The correct response to fluctuations observed in the water-seal chamber of a chest tube is to continue to monitor the situation. This is because fluctuations in the water-seal chamber, also known as tidaling, are typically expected during normal respiratory cycles. Such fluctuations indicate that the chest tube is functioning properly, allowing for air or fluid to be drained from the pleural space while still maintaining a one-way seal. Monitoring the situation allows the nurse to assess any changes in the pattern or intensity of fluctuations that may indicate complications. If fluctuations cease and the water level remains constant, this may signify an obstruction or that the lung has re-expanded, which warrants further assessment. Therefore, maintaining close observation ensures that any relevant changes can be addressed promptly. Documentation of findings is important but is part of the ongoing process rather than an immediate response upon observing fluctuations. Checking for kinks in the tubing and increasing suction pressure are interventions that may be necessary if further symptoms or issues arise, but they are not appropriate first responses if the observed fluctuations are within a normal range.