A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply)

Keeping the drainage system below the level of the client's chest prevents backflow of fluid or air into the
pleural space and maintains negative pressure in the system.

a) Disconnecting the chest tube from the drainage system during transport is dangerous and can cause pneumothorax, infection, or bleeding. The chest tube should remain connected to the drainage system at all times unless ordered by the provider.
b) Emptying the collection chamber prior to transport is unnecessary and can interfere with accurate measurement of drainage. The collection chamber should be emptied only when it is full or at the end of each shift.
c) Clamping the chest tube prior to transferring the client to a wheelchair is contraindicated and can cause tension pneumothorax, as it prevents air from escaping the pleural space. The chest tube should only be clamped for a brief period when changing the drainage system or checking for air leaks, and only with a provider's order.

Continuing to monitor the client is the appropriate action for the nurse to take, as a rise in the water seal chamber with client inspiration is a normal and expected finding. The water seal chamber acts as a one-way valve that allows air to exit from the pleural space and prevents air from entering. The water level in this chamber fluctuates with breathing, rising with inspiration and falling with expiration. This indicates that the chest tube system is functioning properly and that there is no air leak.

a) Immediately notifying the provider is not necessary, as a rise in the water seal chamber with client inspiration is not an abnormal or urgent finding. The nurse should only notify the provider if there are signs of complications, such as persistent bubbling in the water seal chamber, which indicates an air leak, or no fluctuation in the water level, which indicates an obstruction or resolution of pneumothorax.
b) Clamping the chest tube near the water seal is not advisable, as it can cause increased pressure in the pleural space and lead to tension pneumothorax. Clamping the chest tube should only be done for a brief period of time and under specific circumstances, such as changing the drainage system, assessing for an air leak, or preparing for chest tube removal.
d) Repositioning the client toward the left side is not helpful, as it does not affect the water level in the water seal chamber. The nurse should position the client according to their comfort and condition, and avoid placing them flat or on their affected side, as this can impair drainage and ventilation.