A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client’s lung has expanded?

Choice A reason: Hyperthermia. This answer is incorrect because hyperthermia is not a complication of a cervical spinal cord injury, but rather a condition that can worsen the injury. Hyperthermia can increase the metabolic demand and oxygen consumption of the injured spinal cord, leading to more damage and inflammation.

Choice B reason: Absence of bowel sounds. This answer is correct because absence of bowel sounds is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the gastrointestinal system. A cervical spinal cord injury can cause spinal shock, which leads to decreased peristalsis and paralytic ileus.

Choice C reason: Polyuria. This answer is incorrect because polyuria is not a complication of a cervical spinal cord injury, but rather a condition that can occur after the resolution of spinal shock. Polyuria can result from the loss of sympathetic control over the renal system, leading to increased urine output and decreased antidiuretic hormone secretion.

Choice D reason: Weakened gag reflex. This answer is correct because weakened gag reflex is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the respiratory system. A cervical spinal cord injury can cause damage to the cranial nerves that control the gag reflex, leading to difficulty swallowing, aspiration, and pneumonia.

Choice E reason: Hypotension. This answer is correct because hypotension is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the cardiovascular system. A cervical spinal cord injury can cause neurogenic shock, which leads to decreased sympathetic tone, vasodilation, and reduced cardiac output.

Choice A reason: Repositioning the client toward the left side is not necessary or helpful for a client who has a three-chamber closed chest tube system. The chest tube drainage system must always be placed below the drainage site and secured in an upright position to prevent it from being knocked over.

Choice B reason: Continuing to monitor the client is the appropriate action for the nurse to take after noticing a rise in the water seal chamber with client inspiration. The water in the water seal chamber should rise with inhalation and fall with exhalation (this is called tidaling), which demonstrates that the chest tube is patent. This is a normal finding and does not indicate a problem with the chest tube system or the client's condition.

Choice C reason: Clamping the chest tube near the water seal is not recommended for a client who has a three-chamber closed chest tube system. Clamping the chest tube can cause a buildup of air or fluid in the pleural space and increase the risk of complications such as tension pneumothorax or infection. Clamping the chest tube should only be done in certain situations, such as changing the drainage system, checking for an air leak, or removing the chest tube.

Choice D reason: Immediately notifying the provider is not necessary for a client who has a three-chamber closed chest tube system and shows a rise in the water seal chamber with client inspiration. As mentioned above, this is a normal finding and does not indicate a problem with the chest tube system or the client's condition. The nurse should only notify the provider if there are signs of complications, such as continuous bubbling in the water seal chamber, excessive drainage, chest pain, dyspnea, or subcutaneous emphysema.