The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment?
a. Document the tidaling
b. Elevate the head of the bed and notify charge nurse of malfunction of drainage system
c. Add more sterile water to the water seal chamber
d. Turn patient to the affected side
ANS: A
Tidaling or fluctuation in the water seal drainage is an indicator that the negative pressure is preserved and the system is working normally. Document this normal finding.
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