A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction. Which finding requires immediate action by the nurse?
a. Fifty milliliters of blood gushes into the drainage device after the patient coughs.
b. The patient complains of pain at the chest tube insertion site that increases with movement.
c. No bubbling is present in the suction control chamber of the drainage device.
d. Yellow purulent discharge is seen leaking out from around the dressing site.
ANS: C
No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 24 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the physician but is not immediately life threatening.
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