The nurse is caring for a client who has a chest tube in place. Which action by the nurse is appropriate in regards to monitoring intake and output?
1. Drawing a line next to the level of the drainage on the drainage system with the time and date
2. Documenting the action in the nursing notes
3. Recording data on a chest tube drainage flow sheet
4. Documenting the information in primary care provider's notes
Correct Answer: 1
The nurse should draw a line on the drainage system next to the current level of drainage. This allows the nurse measuring output on successive shifts to see where the drainage was measured last, and provides continuity of care. The nurse would not document this action in the nursing notes unless the client had excessive drainage requiring intervention. Most facilities do not have a chest tube drainage flow sheet, and there would be no reason to document the information in the primary care provider's notes.
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