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    Ati lpn n113 pharmacology proctored exam

    The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level (tidaling) in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

    Explanation & Rationale

    A. Inform the HCP: Notifying the healthcare provider is unnecessary in this case, as tidaling in the water seal chamber is an expected and normal finding. It indicates that the chest tube is patent and responding to changes in thoracic pressure during respiration. B. Continue to monitor the client: Tidaling reflects normal movement of air and fluid in response to respiration, suggesting the chest tube is functioning correctly. The most appropriate action is to continue monitoring the client. C. Reinforce the occlusive dressing: There is no indication that the dressing is loose or compromised. Without evidence of air leak or tube displacement, reinforcing the dressing is not necessary at this point. D. Encourage the client to deep breathe: While deep breathing is important for lung expansion and preventing complications like atelectasis, it is not specifically indicated in response to the observation of tidaling.

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