A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Sims' position, with the head of the bed flat 2. Prone, with the head turned to the side supported by a pillow 3. Lying in bed on the affected side, with the head of the bed elevated 45 degrees 4. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees Correct Answer 4. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees Rationale: To facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the bed, leaning over a bedside table, with the feet supported on a stool or lying in bed on the unaffected side, with the head of the bed elevated 45 degrees (Fowler's position). Options 1, 2, and 3 are incorrect. The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take? 1. Notify the Rapid Response Team. 2. Finish the suctioning as quickly as possible. 3. Contact the respiratory department to suction the client. 4. Discontinue suctioning until the client is stabilized and monitor vital signs. Correct Answer 4. Discontinue suctioning until the client is stabilized and monitor vital signs. Rationale: If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the registered nurse. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and health care provider may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified. The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply. 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Correct Answer 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water-seal chamber indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hour is considered excessive and requires registered nurse and health care provider notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space. The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? 1. Empty the drainage.